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Patients With Malignancy Requiring Urgent Therapy

CASE 2. Bilateral Renal Swelling Induced by Adult T-Cell Leukemia/Lymphoma

First Department of Internal Medicine, and Division of Surgical Pathology, Osaka Medical College, Takatsuki City, Osaka, Japan

A 55-year-old Japanese man was admitted to our hospital with confusion and hypouresis. Physical examination showed bilateral renal swelling (Fig 1). Serum calcium and creatinine levels were 4.58 mmol/L and 497.6 µmol/L, respectively. His plasma parathyroid hormone (PTH) –related protein (PTHrP) level was elevated to 4.2 pmol/L (normal, < 0.6 pmol/L), and intact PTH was suppressed to 6 pg/mL (normal range, 10 to 65 pg/mL). A serologic test for antihuman T-cell leukemia virus type-1 antibody was positive, and bone marrow biopsy demonstrated diffuse infiltration of abnormal T lymphocytes, characterized by an irregular nuclear contour and variably prominent nucleoli. Consequently, adult T-cell leukemia/lymphoma (ATLL) was diagnosed. Immunohistochemical staining of the bone marrow biopsy showed the abnormal lymphocytes to be positive for PTHrP antibodies (Fig 2). An open renal biopsy demonstrated relatively normal glomerulus; however there was calcification, degeneration, and destruction of the tubular epithelium (Fig 3). Unfortunately, 2 days later, the patient died suddenly from cardiac arrhythmia.

View larger version (83K): [in this window] [in a new window]   Fig 1.

View larger version (133K): [in this window] [in a new window]   Fig 2.

View larger version (131K): [in this window] [in a new window]   Fig 3.

Hypercalcemia induces variable degrees of renal impairment, as has been shown by milk-alkali syndrome, and the pathophysiology of this syndrome is complex.⁴ In milk-alkali syndrome, calcium deposition is not usually evident on radiologic examination. Furthermore, there have been very few reports of these findings with renal biopsy. Histologic examination demonstrates hyalinization of the glomeruli, degeneration of the tubular epithelium, calcium deposition, and inflammatory reactive changes.⁵ Although renal infiltration in ATLL has been previously reported,⁶ to our knowledge to date, the present article is the first reported case of renal failure due to hypercalcemia in which biopsy has been performed. Hypercalcemia may induce renal failure, and physicians should be cognizant of this complication when elevated levels of serum PTHrP are detected in hypercalcemic patients with malignancy.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

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3. Ikeda K, Ohno H, Hane M, et al: Development of a sensitive two-site immunoradiometric assay for parathyroid hormone-related peptide: Evidence for elevated levels in plasma from patients with adult T-cell leukemia/lymphoma and B-cell lymphoma. J Clin Endocrinol Metab 79:1322-1327, 1994[Abstract]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yokote, T. Articles by Hanafusa, T. Search for Related Content PubMed PubMed Citation Articles by Yokote, T. Articles by Hanafusa, T. Social Bookmarking                            What's this?