Pancreatitis aguda en el escenario de hipercalcemia por hiperparatiroidismo primario / Acute pancreatitis in the setting of hypercalcemia due to primary hyperparathyroidism

Introducción: describir el caso de un paciente con pancreatitis aguda secundaria a hipercalcemia por hiperparatiroidismo prImario. Esta es una causa poco frecuente de pancreatitis, asociada a morbimortalidad significativa en caso de no ser diagnosticada oportunamente Caso clínico: un hombre de 44 años, con antecedente de pancreatitis de presunto origen biliar que había requerido previamente colecistectomía, consultó por dolor abdominal y náuseas. Los estudios complementarios fueron compatibles con un nuevo episodio de pancreatitis aguda. Presentaba hipercalcemia y hormona paratiroidea (PTH) elevada, configurando hiperparatiroidismo primario. La gammagrafía informó hallazgos compatibles con adenoma paratiroideo. Se inició tratamiento con reanimación hídrica y analgesia con adecuada disminución de calcio sérico y resolución de dolor abdominal. Después de la paratiroidectomía se logró normalizar los niveles de calcio y PTH. Discusión: la pancreatitis aguda es una condición potencialmente fatal, por lo que la sospecha de causas poco frecuentes como la hipercalcemia debe tenerse en cuenta. El tratamiento de la hipercalcemia por adenoma paratiroideo se basa en reanimación hídrica adecuada y manejo quirúrgico del adenoma, con el fin de evitar recurrencia de pancreatitis y mortalidad. (AU)

Introduction: we describe the case of a patient with acute pancreatitis secondary to hypercalcemia due to primary hyperparathyroidism. This is a rare cause of pancreatitis associated with significant morbidity and mortality if not diagnosed in time. Clinical case: a 44-year-old man with a history of pancreatitis of presumed biliary origin, which had previously required cholecystectomy, consulted for abdominal pain and nausea. The laboratory findings were compatible with a new episode of acute pancreatitis. He presented hypercalcemia and an elevated parathyroid hormone (PTH), configuring primary hyperparathyroidism. Scintigraphy was performed, yielding findings compatible with parathyroid adenoma. Treatment with fluid resuscitation and analgesia was started, resulting in an adequate decrease in serum calcium and resolution of abdominal pain. After parathyroidectomy, calcium and PTH levels were normalized. Discussion: acute pancreatitis is a potentially fatal condition; therefore the suspicion of rare causes, such as hypercalcemia, should be considered. The treatment of hypercalcemia due to parathyroid adenoma is based on adequate fluid resuscitation and surgical management of the adenoma, to avoid recurrence of pancreatitis and death. (AU)

Leucemia plasmocitária primária: relato de caso e revisão sistemática sobre seus fatores prognósticos / Primary plasma cell leukemia: a case report and systematic review of prognostic factors / Leucemia primaria de células plasmáticas: reporte de caso y revisión sistemática de sus factores pronósticos

A leucemia de células plasmocitárias (LCP) é uma neoplasia hematológica rara, de caráter agressivo, ainda sem consenso quanto ao melhor esquema terapêutico e prognóstico da doença. Alguns estudos a consideram como uma variante do mieloma múltiplo. O objetivo deste estudo foi realizar um relato de caso e desenvolver uma revisão sistemática da literatura sobre os fatores prognósticos relacionados a essa enfermidade. Esta revisão sistemática seguiu o protocolo PRISMA, utilizou o PubMED como base de dados, buscando estudos que avaliassem fatores prognósticos da LCP. Os estudos selecionados foram posteriormente avaliados quanto a sua qualidade pelo protocolo STROBE. A primeira busca identificou 260 artigos. Após aplicado critério de exclusão, dez foram selecionados. Destes, oito avaliaram fatores prognósticos clínicos e laboratoriais; cinco avaliaram, além disso, fatores citogenéticos; e um avaliou apenas a idade como fator prognóstico. A qualidade dos estudos, avaliada pelo protocolo STROBE, apresentou uma classificação média de 79,1%. Nos estudos analisados, idade > 65 ou > 60 anos, performance status ECOG > 2, hipercalcemia, aumento de lactato desidrogenase (LDH), aumento da creatinina, plaquetopenia e hipoalbuminemia foram encontrados como preditores de prognóstico ruim. Foram também demonstradas alterações citogenéticas consideradas de alto risco, como as translocações e deleções de genes. Diversas condições clínicas, laboratoriais e citogenéticas parecem estar associadas ao pior prognóstico na LCP. O conhecimento desses fatores pode interferir na prática clínica. Entretanto, ainda são necessários estudos mais robustos, multicêntricos e com maior número amostral para aprofundar o conhecimento sobre essa patologia.

Plasma Cell Leukemia (PCL) is rare and aggressive hematologic disorder, with no consensus on the best therapeutic scheme or disease prognosis. Some studies consider it to be a variant of multiple myeloma. This research sought to report a PCL case and to present a systematic literature review on its prognostic factor related. Bibliographic search followed the PRISMA protocol, and was conducted on the PubMED database to identify studies on PCL prognostic factors. Of the 260 articles identified, only ten were included after application of exclusion criteria. Of these, eight evaluated clinical and laboratorial prognostic factors; five assessed cytogenetic factors; and only one investigated age as a prognostic factor. Quality of the selected studies was evaluated by STROBE protocol, presenting a median classification of 79.1%. Age >65 or >60 years old, status performance ECOG>2, hypercalcemia, increased DHL, increased creatinine, thrombocytopenia, and hypoalbuminemia were the factors identified as predictors of a bad prognosis. Studies also showed high-risk cytogenetic abnormalities such as genetic translocation and deletions. Many clinical, laboratorial and cytogenetic conditions seem to be related to a worse PCL prognosis. Since knowledge of these factor can interfere in the clinical practice, more robust studies are needed on this pathology.

La leucemia de células plasmáticas (LCP) es una neoplasia hematológica rara, de carácter agresivo, sin consenso sobre el mejor régimen terapéutico y pronóstico de la enfermedad. Algunos estudios la consideran como una variante del mieloma múltiple. El objetivo de este estudio fue realizar un reporte de caso y desarrollar una revisión sistemática de la literatura sobre los factores pronósticos relacionados con esta enfermedad. Esta revisión sistemática siguió el protocolo PRISMA, utilizó PubMED como base de datos para la búsqueda de estudios que evaluaran los factores pronósticos para LCP. Los estudios seleccionados fueron posteriormente evaluados por su calidad mediante el protocolo STROBE. La primera búsqueda identificó 260 artículos. Después de aplicados los criterios de exclusión, se seleccionaron diez. De estos, ocho evaluaron los factores pronósticos clínicos y de laboratorio, cinco evaluaron también los factores citogenéticos y uno evaluó la edad solo como factor pronóstico. La calidad de los estudios, evaluada por el protocolo STROBE, presentó una calificación promedio del 79,1%. En los estudios analizados, la edad > 65 o > 60 años, el estado funcional ECOG > 2, la hipercalcemia, el aumento de lactato deshidrogenasa (LDH), el aumento de creatinina, la trombocitopenia y la hipoalbuminemia fueron los predictores de mal pronóstico. También se demostraron alteraciones citogenéticas que se consideraron de alto riesgo, como translocaciones y deleciones de genes. Varias condiciones clínicas, de laboratorio y citogenéticas parecen estar asociadas con peor pronóstico en LCP. El conocimiento de estos factores puede interferir en la práctica clínica. Sin embargo, aún se necesitan estudios más robustos, multicéntricos y con mayor tamaño muestral para profundizar en el conocimiento sobre esta patología.

Crisis hipercalcémica como causa de pancreatitis aguda / Hypercalcemia as a cause of acute pancreatitis. Report of one case

Severe hypercalcemia may cause acute pancreatitis. We report a 75-yearold male presenting with abdominal pain and confusion. The initial laboratory showed elevated amylase levels and a serum calcium of 19.0 mg/dl with highly elevated parathormone levels. An abdominal CT scan disclosed pancreatitis. A neck CT scan showed a parathyroid tumor, which was successfully excised. The pathology of the surgical piece showed a parathyroid adenoma.

Generalidades de las principales urgencias en el paciente oncológico: revisión de tema / Overview of the main emergencies in cancer patients: Review / Generalidades das principais urgências no paciente oncológico: revisão de tema

Las urgencias oncológicas son complicaciones comunes de la evolución natural del tumor o de su manejo. Algunas pueden presentarse de manera sutil y ser pasadas por alto, lo que aumenta la morbimortalidad. El objetivo de esta revisión narrativa es recopilar información actualizada de las principales complicaciones oncológicas, para ello se realizó una revisión de artículos originales, revisiones sistemáticas y narrativas en bases de datos como Scopus, SciELO, PubMed, ScienceDirect y en el buscador Google Scholar. Se seleccionaron 63 referencias que mostraran información relevante acerca de las urgencias oncológicas planteadas para el desarrollo del artículo. En la revisión se discute que las complicaciones pueden clasificarse de acuerdo con su origen en infecciosas (neutropenia febril), metabólicas (síndrome de lisis tumoral e hipercalcemia maligna) y obstructivas (síndrome de vena cava superior, obstrucción intestinal, compresión medular y taponamiento cardiaco). El diagnóstico requiere un alto índice de sospecha, el médico debe tener la capacidad resolutiva y el conocimiento necesarios para el manejo y hacer uso racional de los recursos diagnósticos. Es necesario adoptar medidas terapéuticas que impacten positivamente en el pronóstico y que reduzcan la morbimortalidad.

Oncological emergencies are common complications resulting from the natural evolution of the tumor or its management; however, some of them may be subtle or even overlooked, which contributes to greater morbidity and mortality. Our aim was to gather updated information on the main oncological complications. A narrative literatura review was performed by searching for original articles, systematic reviews and narratives, in databases such as Scopus, SciELO, PubMed, ScienceDirect and in the Google Scholar search engine. 63 references were selected that addressed relevant information about the oncological emergencies raised for the development of the article. According to their origin, complications can be classified into infectious (febrile neutropenia), metabolic (tumor lysis syndrome and malignant hypercalcemia) and obstructive (superior vena cava syndrome, intestinal obstruction, spinal cord compression and cardiac tamponade). Facing these complications requires a high level of suspicion; the physician must be able to resolve each complication and have the necessary knowledge to approach each case, with a rational use of diagnostic resources. It is also necessary to adopt therapeutic measures that positively impact patients. patient prognosis, decreasing morbidity and death.

As urgências oncológicas são complicações comuns da evolução natural do tumor ou do seu manejo. Algumas podem apresentar-se de maneira sutil e ser passadaspor encima, o que aumenta a morbimortalidade. O objetivo desta revisão narrativa é recopilar informação atualizada das principais complicações oncológicas, para isso se realizou uma revisão de artigos originais, revisões sistemáticas e narrativas em bases de dados como Scopus, SciELO, PubMed, ScienceDirect e no buscador Google Scholar. Se selecionaram 63 referências que mostraram informação relevante sobre às urgências oncológicas apresentadas para o desenvolvimento do artigo. Na revisão se discuteque as complicações podem classificar-se de acordo com a sua origem em infecciosas (neutropenia febril), metabólicas (síndrome de lise tumoral e hipercalcemia maligna) e obstrutivas (síndrome de veia cava superior, obstrução intestinal, compressão medular e entupimento cardíaco). O diagnóstico requere um alto índice de suspeita, o médico deve ter a capacidade resolutiva e o conhecimento necessário para o manejo e fazer uso racional dos recursos diagnósticos. É necessário adotar medidas terapêuticas que impactem positivamente no prognóstico e que reduzam a morbimortalidade.

Crisis hipercalcémica, presentación inusual de adenoma paratiroideo: reporte de 2 casos / Hypercalcemic crisis, unusual presentation of parathyroid adenoma

La crisis hipercalcémica (CH) es una emergencia endocrina inusual, definida por la presencia de calcemia > 14 mg/dl asociada a disfunción renal, alteraciones cardiovasculares, gastrointestinales y del sensorio; también podría considerarse en pacientes con síntomas graves y calcemia menor. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las etiologías más comunes de la hipercalcemia (90% de los casos); sin embargo, rara vez el primero se presenta como CH. Debido a la alta mortalidad asociada a esta entidad, es de gran importancia establecer diagnóstico y tratamiento precoces. Presentamos dos pacientes con crisis hipercalcémica como primera manifestación del HPTP, el 1.° con bloqueo auriculoventricular (AV) completo y el 2.° con pancreatitis aguda. La anatomía patológica (AP) reveló adenoma oxifílico en ambos casos, que es una variante histológica poco frecuente y puede manifestarse clínicamente de forma grave. Conclusiones: los adenomas paratiroideos son causa poco frecuente de CH. Consideramos el tipo histológico observado (adenoma oxifílico) como probable factor condicionante. La pancreatitis y especialmente el bloqueo AV son manifestaciones poco frecuentes de la CH. Resaltamos la importancia de la determinación de los niveles de calcio dentro de la evaluación inicial de todo paciente con bloqueo AV. (AU)

Hypercalcemic crisis (HC) is an unusual endocrine emergency, defined as the presence of serum calcium > 14 mg/dl related to kidney dysfunction, cardiovascular, gastrointestinal and sensory disturbances. It could also be considered in patients with severe symptoms and lower serum calcium levels. Primary hyperparathyroidism (PHPT) and malignant neoplasms are the most common hypercalcemia etiologies (90% of cases), nevertheless, the former hardly ever occurs as HC. Due to the high mortality associated with HC, it is crucial to establish early diagnosis and treatment.We report two patients with HC as the first manifestation of PHPT; the former with atrioventricular (AV) block and the latter with acute pancreatitis. Pathology revealed oxyphilic adenoma in both cases, which is an infrequent histological variant that can have a severe clinical manifestation. Conclusions: parathyroid adenomas are a rare cause of HC. We consider the histological type observed (oxyphilic adenoma) as a probable conditioning factor. Pancreatitis and especially AV block are rare manifestations of HC. We emphasize the importance of determining calcium levels in the initial evaluation of all patients with AV block. (AU)

Hipocalcemia posterior a tiroidectomía total: Análisis de dosis para suplemento rutinario profiláctico / Hypocalcemia after total thyroidectomy: Dose analysis for routine prophylactic supplementation

Introducción. La hipocalcemia es la complicación más frecuente de la tiroidectomía. La profilaxis con calcio/calcitriol es una alternativa costo-efectiva, sencilla y expedita para disminuir esta situación, sin alterar la función paratiroidea residual. Lo que no está claro es si hay superioridad de una dosis frente a otra, por lo que el objetivo de este estudio fue evaluar el comportamiento entre diferentes esquemas de profilaxis para hipocalcemia. Métodos. Estudio de cohorte retrospectivo de adultos operados en un hospital de cuarto nivel, entre febrero de 2017 y diciembre de 2020. Se calculó la tasa de síntomas, la hipocalcemia e hipercalcemia bioquímica en el control postquirúrgico durante las siguientes dos semanas. Se hizo análisis bivariado y multivariado entre dosis de calcio/calcitriol, otros factores asociados y los desenlaces mencionados. Resultados. Se incluyeron 967 pacientes. El 10 % presentaron síntomas. No hubo diferencias significativas en el calcio sérico del control posquirúrgico entre los grupos con distintas dosis de calcio. La dosis de carbonato de calcio >3600 mg/día y el calcio en las primeras 24 horas de cirugía se asociaron a la presencia de síntomas. La dosis de calcitriol <1 mcg/día y el bocio aumentaron el riesgo de hipocalcemia bioquímica, mientras que la dosis de 1,5 mcg/día lo disminuyó. Ninguna variable evaluada se asoció a hipercalcemia bioquímica. Conclusiones. Podemos establecer que dosis altas de carbonato de calcio no se asocian con menos hipocalcemia bioquímica, lo cual está a favor de usar dosis intermedias (3600 mg/día). De forma similar, la dosis de calcitriol de 1,5 mcg/día disminuye el riesgo de este desenlace. La identificación de variables que aumentan o disminuyen el riesgo de hipocalcemia posterior a tiroidectomía, como bocio o el nivel de calcio en las primeras 24 horas para este estudio, pueden determinar ajustes individuales en la dosis rutinaria profiláctica de calcio/calcitriol.

Introduction. Hypocalcemia is the most frequent complication of thyroidectomy. Calcium/calcitriol prophylaxis is a cost-effective, simple and expeditious alternative to reduce this situation, without altering residual parathyroid function. It is not clear whether there is superiority of one dose over another, so the objective of this study was to evaluate the behavior between prophylaxis doses for hypocalcemia. Methods. Retrospective cohort study of adults operated in a fourth level hospital, between February 2017 and December 2020. The rate of symptoms, biochemical hypocalcemia and hypercalcemia was calculated in the post-surgical control during the following two weeks. Bivariate and multivariate analyses were performed between calcium/calcitriol dose, other associated factors, and the mentioned outcomes. Results. Out of the 967 patients included, 10% presented symptoms. There were no significant differences in postoperative control serum calcium between the groups with different doses of calcium. The dose of calcium carbonate > 3600 mg/day and calcium in the first 24 hours of surgery were associated with the presence of symptoms. The dose of calcitriol <1 mcg/day and goiter increased the risk of biochemical hypocalcemia, while the dose of 1.5 mcg / day decreased it. No variable evaluated was associated with biochemical hypercalcemia. Conclusion. We can establish that high doses of calcium are not less associated with biochemical hypocalcemia, which is in favor of intermediate doses (i.e. 3600mg/day). In a similar way, the calcitriol dose of 1.5mcg/day decreases the risk of this outcome. The identification of variables that increase or decrease the risk of this complication (goiter or the 24h serum calcium in this study) can decide settings in the rutinary prophylactic dose of calcium/calcitriol.

Familial hypocalciuric hypercalcemia as a differential diagnosis of primary hyperparathyroidism with negative images / Hipercalcemia hipocalciúrica familiar como diagnóstico diferencial de hiperparatiroidismo primario con imágenes negativas / Hipercalcemia hipocalciúrica familiar como diagnóstico diferencial de hiperparatireoidismo primário com imagens negativas

Introduction. Familial hypocalciuric hypercalcemia is a rare inherited calcium metabolism disorder in which an alteration of the parathyroid hormone secretion set-point causes hypercalcemia with relative hypocalciuria. Some data suggest that its prevalence is around 74.1 per 100,000 inhabitants. Often, patients are asymptomatic. However, they can develop mild symptoms and an overactive parathyroid adenoma, its main differential diagnosis. The objective was to describe a patient's case and highlight the importance of clinical suspicion and diagnosis to avoid unnecessary surgical neck explorations for parathyroid adenomas. Case report. This is the case of a 40-year-old man with a biochemical profile compatible with primary hyperparathyroidism with anatomical and functional images negative for adenoma and a calcium/creatinine clearance ratio below 0.001, considering familial hypocalciuric hypercalcemia. Genetic studies evidence a mutation in the calcium sensor receptor gene and confirm the diagnosis. Discussion. Familial hypocalciuric hypercalcemia's main differential diagnosis is an overactive parathyroid adenoma. For both, mild or no symptoms may be present; serum calcium exceeds the upper limit, and parathormone is more than 25pg/ml. The calcium/creatinine clearance ratio should be used to differentiate one from the other and avoid unnecessary surgical neck explorations. Besides the lack of information on this topic, evidence supports the use of calcimimetics to treat symptomatic hypercalcemia. Conclusions. Patients with mild hypercalcemia with parathyroid hormone readings above 25pg/ml and a calcium/creatinine clearance ratio below 0.001, or patients with primary hyperparathyroidism with negative imaging, should not undergo surgical neck explorations. In these cases, familial hypocalciuric hypercalcemia is a reliable diagnosis; Cinacalcet may be administered in cases of symptomatic hypercalcemia.

Introducción. La hipercalcemia hipocalciúrica familiar es un trastorno hereditario poco común del metabolismo del calcio en donde una alteración del punto de ajuste de la secreción de hormona paratiroidea ocasiona hipercalcemia con hipocalciuria relativa. Algunos datos sugieren que su prevalencia es de alrededor de 74.1 por 100,000 habitantes. Los pacientes muchas veces son asintomáticos. Sin embargo, pueden desarrollar síntomas leves y un adenoma paratiroideo hiperactivo, que representa su principal diagnóstico diferencial. El objetivo fue describir el caso de un paciente y resaltar la importancia de la sospecha y el diagnóstico clínico para evitar exploraciones quirúrgicas cervicales innecesarias en búsqueda de adenomas paratiroideos. Reporte de caso. Este es el caso de un hombre de 40 años con un perfil bioquímico compatible con hiperparatiroidismo primario, con imágenes anatómicas y funcionales negativas para adenoma, además de una relación de depuración de calcio/creatinina menor a 0.001, con consideración de hipercalcemia hipocalciúrica familiar. Los estudios genéticos evidencian una mutación en el gen del receptor sensor del calcio y confirman el diagnóstico. Discusión. El principal diagnóstico diferencial de la hipercalcemia hipocalciúrica familiar es un adenoma paratiroideo hiperactivo. En ambos casos, es posible que no haya síntomas o que estos sean leves; el calcio sérico excede al límite superior, y la paratohormona es mayor de 25pg/ml. Se debe usar la relación de depuración de calcio/creatinina para diferenciar entre estas patologías y evitar exploraciones quirúrgicas cervicales innecesarias. Aparte de la falta de información sobre este tema, la evidencia apoya el uso de calciomiméticos para tratar la hipercalcemia sintomática. Conclusiones. Los pacientes con hipercalcemia leve, con valores de hormona paratiroidea mayores de 25pg/ml y con una relación de depuración de calcio/creatinina menor de 0.001, o los pacientes con hiperparatiroidismo primario con imágenes negativas, no deben ser sometidos a exploraciones quirúrgicas cervicales. En estos casos, la hipercalcemia hipocalciúrica familiar representa un diagnóstico confiable; se puede administrar Cinacalcet en casos de hipercalcemia sintomática.

Introdução. A hipercalcemia hipocalciúrica familiar é um distúrbio hereditário raro do metabolismo do cálcio, no qual uma alteração no ponto de ajuste da secreção do hormônio da paratireóide causa hipercalcemia com hipocalciúria relativa. Alguns dados sugerem que sua prevalência gira em torno de 74.1 por 100,000 habitantes. Os pacientes geralmente são assintomáticos. No entanto, eles podem desenvolver sintomas leves e um adenoma de paratireoide hiperativo, que representa seu principal diagnóstico diferencial. O objetivo foi descrever o caso de um paciente e destacar a importância da suspeita clínica e do diagnóstico para evitar exploração cirúrgica cervical desnecessária em busca de adenomas de paratireoide. Relato de caso. É o caso de um homem de 40 anos com perfil bioquímico compatível com hiperparatireoidismo primário, com imagens anatômicas e funcionais negativas para adenoma, além de relação depuração de cálcio/creatinina menor que 0.001, considerando hipercalcemia hipocalciúrica familiar. Estudos genéticos revelam uma mutação no gene receptor da sensibilidade ao cálcio e confirmam o diagnóstico. Discussão. O principal diagnóstico diferencial da hipercalcemia hipocalciúrica familiar é um adenoma de paratireoide hiperativo. Em ambos os casos, os sintomas podem estar ausentes ou leves; o cálcio sérico excede o limite superior e o hormônio da paratireóide é superior a 25pg/ml. A relação depuração de cálcio/creatinina deve ser usada para diferenciar entre essas patologias e evitar exploração cirúrgica cervical desnecessária. Além da falta de informações sobre esta questão, as evidências apoiam o uso de calcimiméticos para tratar a hipercalcemia sintomática. Conclusões. Pacientes com hipercalcemia leve, com valores de hormônio da paratireóide maiores que 25pg/ml e uma relação de depuração de cálcio/creatinina menor que 0.001, ou pacientes com hiperparatireoidismo primário com imagens negativas, não devem ser submetidos a exploração cirúrgica cervical. Nesses casos, a hipercalcemia hipocalciúrica familiar representa um diagnóstico confiável; Cinacalcet pode ser administrado em casos de hipercalcemia sintomática.

Case reports of hypercalcemia and chronic renal disease due to cosmetic injections of polymethylmethacrylate (PMMA) / Relatos de casos de hipercalcemia e doença renal crônica devidas a injeções de polimetilmetacrilato (PMMA) por razões estéticas

Abstract Cosmetic injections of fillers are common plastic surgery procedures worldwide. Polymethylmethacrylate (PMMA) is a filler approved only for minimally invasive procedures in facial tissue and is among the most frequently used injectable substances for cosmetic purposes. Injection of a large volume of PMMA may lead to the development of severe hypercalcemia and chronic kidney damage in a probably underestimated frequency. In such cases, hypercalcemia develops due to a granulomatous foreign body reaction with extrarenal production of calcitriol. In the present report, we describe the cases of two patients who received injections of large volumes of PMMA and developed severe hypercalcemia and advanced chronic kidney disease. These reports highlight the importance of adhering to regulations regarding the use of PMMA and properly informing patients of the possibility of complications before undertaking such procedures.

Resumo Injeções de preenchimento de caráter estético são procedimentos comuns em cirurgia plástica em todo o mundo. O polimetilmetacrilato (PMMA) é um material de preenchimento aprovado apenas para procedimentos minimamente invasivos no tecido facial, e está entre as substâncias injetáveis mais frequentemente usadas para fins estéticos. A injeção de um grande volume de PMMA pode levar ao desenvolvimento de hipercalcemia grave e lesão renal crônica em uma frequência provavelmente subestimada. Nesses casos, a hipercalcemia se desenvolve devido a uma reação granulomatosa de corpo estranho, secundária à produção extrarenal de calcitriol. No presente artigo, descrevemos os casos de dois pacientes que receberam injeções de grandes volumes de PMMA e desenvolveram hipercalcemia grave e doença renal crônica avançada. Esses relatos destacam a importância de seguir as regulamentações sobre o uso do PMMA e informar adequadamente os pacientes sobre a possibilidade de complicações antes de realizar tais procedimentos.

Sarcoid-like granulomatous myositis-associated hypercalcemia. An infrequent case to consider / Hipercalcemia asociada a miositis granulomatosa sarcoidea simil- sarcoidea. Un caso infrecuente a considerar

Abstract PTH-independent hypercalcemia due to granulomatous disease is well-documented and sarcoidosis is the most characteristic disease, although there are others. We describe a case of sarcoid-like granulomatous myositis. An 87-year-old man was referred with tetraparesis and hypercalcemia (albumin-corrected calcium of 13.4 mg/dl) following a trip to the Caribbean. The evaluation showed a suppressed PTH, 25-hydroxy vitamin D of 7.5 ng/ml, 18F-FDG PET/CT showed markedly increased uptake in intercostal, back, shoulder, but tock and thigh muscles and a deltoid biopsy confirmed extensive granulomatous myositis. He was prescribed glucocorticoids which resulted in normalized plasma calcium levels and complete recovery from tetraparesis. Sarcoid-like granulomatous myositis should be incorporated into the differential diagnosis of PTH-independent hypercalcemia, especially in the absence of clinical features of sarcoidosis and with special emphasis on the use of 18F-FDG PET/CT to ensure a correct approach.

Resumen La hipercalcemia PTH-independiente asociada a enfermedades granulomatosas está bien documentada y la sarcoidosis es la enfermedad más característica, a pesar de que existen otras. Des cribimos un caso de miositis granulomatosa simil-sarcoidea. Un hombre de 87 años consultó por tetraparesia e hipercalcemia (calcio corregido por albúmina 13.4 mg/dl) luego de un viaje al Caribe. La evaluación mostró una PTH suprimida, 25-hidroxivitamina D 7.5 ng/ml, 18F-FDG PET/CT mostró marcado aumento de captación a nivel de musculatura intercostal, dorsal, deltoidea, glúteos y muslos. Una biopsia deltoidea confirmó una miositis granulomatosa extensa. Se prescribieron glucocorticoides, resultando en normalización del calcio plasmático y completa recuperación de la tetraparesia. La miositis granulomatosa simil-sarcoidea debe ser incorporada den tro del diagnóstico diferencial de la hipercalcemia PTH-independiente, especialmente en ausencia de hallazgos clínicos de sarcoidosis y con especial énfasis en el uso de 18F-FDG PET/CT para su correcta aproximación.

Hipercalcemia en paciente pediátrica con disgerminoma ovárico: a propósito de un caso / Hypercalcemia in a pediatric patient with ovarian dysgerminoma: A case report

La hipercalcemia asociada a tumores malignos es una entidad poco frecuente en pediatría (0,5-1,3 % de los cánceres pediátricos). Es causada por diferentes mecanismos fisiopatológicos y los síntomas de presentación suelen ser inespecíficos, pero potencialmente graves. Presentamos un caso clínico de una paciente de 12 años con diagnóstico de disgerminoma ovárico bilateral. La enfermedad se presentó con hipercalcemia grave, tratada con hiperhidratación asociada a diuréticos de asa, bifosfonatos y, por último, la resección quirúrgica del tumor, que permitió la resolución definitiva del cuadro. A pesar de tratarse de un trastorno hidroeléctrico poco habitual en pediatría, dada la potencial gravedad de la hipercalcemia, es importante la detección y el tratamiento tempranos, con el fin de evitar complicaciones en el corto y el largo plazo

Hypercalcemia associated with malignant tumors is a rare entity in pediatrics (0.5-1.3 % of pediatric cancers). It responds to different pathophysiological mechanisms and the typical symptoms shown are usually nonspecific, but potentially serious. We present a clinical case of a 12-year-old patient with a bilateral ovarian dysgerminoma who was diagnosed with severe hypercalcemia at the onset, which required hyperhydration associated with loop diuretics, bisphosphonates and, eventually, the tumor resection surgery that allowed the final resolution of the clinical picture.Despite being a rare hydroelectric disorder in pediatrics, given the potential severity of hypercalcemia, early detection and treatment are important in order to avoid potential short- and long-term complications.

Puesta al día: carcinoma paratiroideo / An update on parathyroid carcinoma

Parathyroid carcinoma is a rare malignant disease that presents as a sporadic or familial primary hyperparathyroidism (PHP). The latter is associated with some genetic syndromes. It occurs with equal frequency in both sexes, unlike PHP caused by parathyroid adenoma that is more common in women. It should be suspected in cases of severe hypercalcemia, with high parathyroid hormone levels and a palpable cervical mass. Given the difficulty in distinguishing between parathyroid carcinoma and adenoma prior to the surgery, the diagnosis is often made after parathyroidectomy. The only curative treatment is complete surgical resection with oncologic block resection of the primary tumor to ensure free margins. Adjuvant therapies with chemotherapy or radiation therapy do not modify overall or disease-free survival. Recurrences are common and re-operation of resectable recurrent disease is recommended. The palliative treatment of symptomatic hypercalcemia is crucial in persistent or recurrent disease after surgery since morbidity and mortality are more associated with hypercalcemia than with tumor burden.

Causes of hypercalcemia in renal transplant recipients: persistent hyperparathyroidism and others

Hypercalcemia is common in patients after kidney transplantation (KTx) and is associated with persistent hyperparathyroidism in the majority of cases. This retrospective, single-center study evaluated the prevalence of hypercalcemia after KTx. KTx recipients were evaluated for 7 years after receiving kidneys from living or deceased donors. A total of 301 patients were evaluated; 67 patients had hypercalcemia at some point during the follow-up period. The median follow-up time for all 67 patients was 62 months (44; 80). Overall, 45 cases of hypercalcemia were classified as related to persistent post-transplant hyperparathyroidism (group A), 16 were classified as "transient post-transplant hypercalcemia" (group B), and 3 had causes secondary to other diseases (1 related to tuberculosis, 1 related to histoplasmosis, and 1 related to lymphoma). The other 3 patients had hypercalcemia of unknown etiology, which is still under investigation. In group A, the onset of hypercalcemia after KTx was not significantly different from that of the other groups, but the median duration of hypercalcemia in group A was 25 months (12.5; 53), longer than in group B, where the median duration of hypercalcemia was only 12 months (10; 15) (P<0.002). The median parathyroid hormone blood levels around 12 months after KTx were 210 pg/mL (141; 352) in group A and 72.5 pg/mL (54; 95) in group B (P<0.0001). Hypercalcemia post-KTx is not infrequent and its prevalence in this center was 22.2%. Persistent hyperparathyroidism was the most frequent cause, but other important etiologies must not be forgotten, especially granulomatous diseases and malignancies.

Hiperparatiroidismo primario por carcinoma paratiroideo: caso problema y revisión / Primary hyperparathyroidism by parathyroid cancer: case report and review

El carcinoma paratiroideo (CP) es una neoplasia maligna con una incidencia de 0,015 cada 100.000 habitantes por año. Representa el 1% de los diagnósticos de hiperparatiroidismo primario y se manifiesta entre la 4.a y 5.a década de la vida, con una incidencia similar entre hombres y mujeres. La etiología del CP es incierta, ha sido asociada a formas esporádicas o familiares. Está caracterizado por altos niveles séricos de calcio y PTH y el desafío clínico-quirúrgico es el diagnóstico diferencial con otras entidades benignas como el adenoma o la hiperplasia de paratiroides. Aunque el diagnóstico de certeza es anatomopatológico, la sospecha clínica y el uso de métodos de baja complejidad (ecografía) con operadores avezados permite una correcta localización y abordaje pertinente del paciente para dirigir el tratamiento quirúrgico adecuado (resección en bloque) evitando persistencias y recurrencias de enfermedad. Se presenta el caso clínico de un paciente masculino que ingresa por síndrome de impregnación asociado a hipercalcemia, su abordaje diagnóstico, tratamiento y manejo interdisciplinario con discusión y revisión bibliográfica. (AU)

Parathyroid carcinoma (CP) is a malignant disease with an incidence of 0.015 per 100,000 inhabitants per year. It accounts for 1% of primary hyperparathyroidism diagnoses and occurs between the 4th and 5th decade of life, with a similar incidence between men and women. The etiology of CP is uncertain and has been associated with sporadic or family forms. CP is characterized by high serum calcium and PTH levels and the clinical-surgical challenge is the differential diagnosis with other benign entities such as parathyroid adenoma or hyperplasia. Although the diagnosis of certainty is achieved by pathological anatomy examination, the clinical suspicion and the use of low complexity methods (ultrasound) by experienced operators allows a correct localization and a patient-specific approach to direct the appropriate surgical treatment (block resection), avoiding persistence and recurrences of disease. The clinical case of a male patient admitted for severe hypercalcemia with multiple organ disfunction, the diagnostic approaches, treatment, and interdisciplinary management, together with review and discussion of the current literature are presented. (AU)

Multiple myeloma presenting as acute tubulointerstitial nephritis

Background Acute tubulointerstitial nephritis (ATIN) is a very rare paraneoplastic manifestation in patients with multiple myeloma (MM). It is an uncommon pattern of renal disease in such patients. Case presentation We report a case of an 82-year-old male who was admitted with acute kidney injury. Renal biopsy showed typical findings of light chain-associated ATIN with scattered inflammatory cells in the interstitium and associated active tubulitis. No other common manifestations of MM were present at the time of presentation, including hypercalcemia, hyperuricemia, proteinuria, bone pain or lytic bone lesions. Subsequent immunoassays revealed significant serum lambda light chain burden and Bence Jones protein in urine. Immunofluorescence demonstrated linear tubular basement membranes with positive staining for lambda light chain (3+). Electron microscopy (EM) further showed interstitial edema and inflammation. All the aforementioned findings are consistent with ATIN and supported the diagnosis of MM. Conclusions In conclusion, light chain-associated ATIN should be considered in the differential diagnosis of acute interstitial nephritis. Henceforth, serum free light chains as well as serum and urine protein electrophoresis should be included in the workup of such patients.

Anticonvulsivantes y su efecto en el metabolismo de la vitamina D: revisión del tema, a propósito de un caso / Anticonvulsants and their effect on the metabolism of vitamin D: literature review with case report

La epilepsia es una enfermedad neurológica frecuente que afecta a cerca de 50.000 millones de personas en el mundo. En Chile, la prevalencia estimada es de 10.8 a 17 por 1.000 habitantes. La primera opción para su tratamiento son los fármacos antiepilépticos (FAE) los cuales logran un aceptable control de enfermedad en la mayoría de los casos, sin embargo, tienen la potencialidad de desencadenar una serie de efectos adversos destacando entre ellos el desarrollo de hipocalcemia (HC) secundaria a hipovitaminosis D (HD), alteración que por lo general es leve y asintomática. Presentamos el caso de una mujer perimenopausica con antecedente de epilepsia en tratamiento con anticonvulsivante que desarrolla hipocalcemia severa. Además revisamos los mecanismos descritos a través de los cuales los FAE afectan el metabolismo de esta vitamina.

Epilepsy is a common neurological disease that affects about 50,000 million people in the world. The estimated prevalence is 10.8 to 17 per 1.000 inhabitants in Chile. The first option for its treatment are antiepileptic drugs (AEDs) which achieve an acceptable control of the disease in most cases, however, they have the potential to trigger a series of adverse effects (AE) highlighting among them the development of hypocalcemia (HC) secondary to hypovitaminosis D (HD), an alteration that is generally mild and asymptomatic. We present the case of a perimenopausal woman with a history of epilepsy under treatment with an anticonvulsant who develops severe hypocalcemia. We also review the mechanisms described through which AEDs affect the metabolism of this vitamin.

Denosumab can be used successfully as a bridge to surgery in patients with severe hypercalcemia due to primary hyperparathyroidism

SUMMARY Severe hypercalcemia is a medical emergency that requires immediate and aggressive management. Primary hyperparathyroidism (PHPT) often causes severe hypercalcemia. Volume resuscitation, parenteral salmon calcitonin, and administration of intravenous bisphosphonates are common measures used to stabilize patients. However, the use of these measures is inadequate in several patients and may even be contraindicated in individuals with renal insufficiency or severe systemic illness. This study demonstrated the efficacy and safety of denosumab in patients with severe hypercalcemia due to PHPT, when immediate surgery was not feasible. We present four patients with severe hypercalcemia due to PHPT. Immediate surgery was not feasible because the patients had severe systemic illness, such as seizures and altered sensorium (case 1); acute severe pancreatitis (cases 2 and 3); or coronavirus disease 2019 pneumonia (case 4). Intravenous normal saline and parenteral salmon calcitonin were inadequate for controlling hypercalcemia. Intravenous bisphosphonates were avoided because of severe systemic illness in all cases and impaired renal function in three cases. Denosumab was administered to control hypercalcemia and allow the stabilization of patients for definitive surgical management. Following denosumab administration, serum calcium levels normalized, and general condition improved in all patients. Three patients underwent parathyroidectomy after two weeks and another patient after eight weeks. The use of denosumab for the management of severe hypercalcemia due to PHPT is efficacious and safe in patients when immediate surgical management is not feasible due to severe systemic illness.