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3. ... At 40 days after discharge, he visited the emergency department after hypercalcemia and renal dysfunction were detected during a routine visit to his family physician. On readmission, laboratory findings (Table 1) showed serum calcium of 14.4 mg/dL (adjusted for albumin), blood urea nitrogen LY294002 in vitro (BUN) of 51.5 mg/dL, creatinine of 5.37 mg/dL, alkaline phosphatase (ALP) of 1,422 U/L, and gamma-glutamyl transferase (��GTP) of 364 U/L. He had no symptoms other than malaise. The 12-lead electrocardiogram was normal. We suspected that the renal abnormalities had been preceded and caused by hypercalcemia, since his renal function was normal 2 weeks before readmission. While the results for serum levels of intact PTH, parathyroid hormone-related protein (PTHrP), and 1�C25(OH)2 vitamin D were awaited, treatment for hypercalcemia was initiated with IV fluids, bisphosphonate (pamidronate disodium hydrate 30 mg), calcitonin (elcatonin 80 U/day for three days), and IV corticosteroids (prednisolone sodium succinate 120 mg/day for three days, 20 mg/day for two days, and 10 mg/day for two days) (Fig. 3). Figure 3 Clinical course at the second admission. Table 1 Laboratory data at second admission. During the second admission, the serum level of intact PTH was 95 pg/mL (normal, 10�C65 pg/mL) and PTHrP was Lapatinib pmol/L). 99mTc-MIBI parathyroid scintigraphy (Fig. 4) and parathyroid ultrasonography showed no abnormal findings, ruling out primary hyperparathyroidism. Gastroscopy and colonoscopy revealed no abnormalities, and upper gastrointestinal endoscopy showed no evidence of Helicobacter pylori infection. No M protein was detected in blood or urine. Bone marrow biopsy revealed no evidence of malignancy, and screening for human T-lymphotropic virus type 1 (HTLV-1) was negative. Figure 4 99mTc-MIBI parathyroid scintigraphy was negative, and no ectopic parathyroid glands were found. Because ALP and ��GTP levels continued to increase even after the administration of prednisolone, we performed a percutaneous needle liver biopsy on day 26 of the second admission. Histopathological examination showed plasma cell infiltration in Gleason��s area but no active hepatitis or fibrosis. The ratio of IgG4-positive and IgG-positive plasma cells was 0.4 (Fig. 5). This finding was compatible with the diagnosis of IgG4-RD.9 S6 Kinase Figure 5 Liver biopsy. Plasma cells infiltration was noted in Gleason��s area; however, no active hepatitis or fibrosis was seen. The ratio of IgG4-positive/IgG-positive plasma cells was 0.4. The patient��s serum calcium, kidney function, and intact PTH gradually returned to normal by 15 days after the first dose of prednisolone. ALP and ��GTP levels also slowly normalized and were within normal limits three months after corticosteroid therapy was initiated. A repeat PET/CT scan showed resolution of abnormal FDG uptake in the lymph nodes and salivary glands.
