Calcitriol induced hypercalcemia-a rare phenomenon in lung cancer:A case report

BACKGROUND Calcitriol-induced hypercalcemia has been rarely reported in cases of lung cancer;however,it is frequently reported in cases of lymphoid malignancy and granulomatous disease.We present a rare case of hypercalcemia associated with squamous cell cancer of the lung with elevated calcitriol level.CASE SUMMARY A 61-year-old Caucasian female with severe hypercalcemia of 15 mg/dL,which led to a new diagnosis of metastatic lung cancer.Since the parathyroid hormonerelated peptide(PTHrP)level was minimally elevated at 2.1 pmol/L,we believe excessive calcitriol production by tumor cells was the underlying mechanism for hypercalcemia.Calcitriol was significantly elevated at 130 pg/mL with a low 25-hydroxyvitamin D level of 25.9 ng/mL and suppressed PTH level of 8 pg/mL.Corticosteroids are generally used to treat calcitriol-induced hypercalcemia,but we successfully treated our patient with bisphosphonate,highlighting the further utility of bisphosphonates in hypercalcemia treatment.CONCLUSION We believe that the underlying cause of hypercalcemia,in this case of metastatic squamous cell lung carcinoma,was elevated calcitriol,which was likely produced by the tumor cells.In addition to PTHrP,calcitriol levels should be included in the workup for hypercalcemia in cases of lung cancer.However,the pathophysiology and prognostic significance of dysregulated calcitriol production in solid tumors remain unclear and warrant further research.Bisphosphonate may be used as a steroid-sparing therapy even in cases of calcitriol-induced hypercalcemia and warrants further investigation.

Point-of-care ultrasonography spotlight:Could venous excess ultrasound serve as a shared language for internists and intensivists?

Point-of-care ultrasonography(POCUS),particularly venous excess ultrasound(VExUS)is emerging as a valuable bedside tool to gain real-time hemodynamic insights.This modality,derived from hepatic vein,portal vein,and intrarenal vessel Doppler patterns,offers a scoring system for dynamic venous congestion assessment.Such an assessment can be crucial in effective management of patients with heart failure exacerbation.It facilitates diagnosis,quantification of congestion,prognostication,and monitoring the efficacy of decongestive therapy.As such,it can effectively help to manage cardiorenal syndromes in various clinical settings.Extended or eVExUS explores additional veins,potentially broadening its applications.While VExUS demonstrates promising outcomes,challenges persist,particularly in cases involving renal and liver parenchymal disease,arrhythmias,and situations of pressure and volume overload overlap.Proficiency in utilizing spectral Doppler is pivotal for clinicians to effectively employ this tool.Hence,the integration of POCUS,especially advanced applications like VExUS,into routine clinical practice necessitates enhanced training across medical specialties.

Autoimmune diabetes from pembrolizumab:A case report and review of literature

BACKGROUND Immunotherapy,specifically the use of checkpoint inhibitors such as pembrolizumab,has become an important tool in personalized cancer therapy.These inhibitors target proteins on T-cells that regulate the immune response against tumor cells.Pembrolizumab,which targets the programmed cell death 1 receptor on T-cells,has been approved for the treatment of metastatic melanoma and nonsmall cell lung cancer.However,it can also lead to immune-related side effects,including pneumonitis,colitis,thyroid abnormalities,and rare cases of type 1 diabetes.CASE SUMMARY The case presented involves an adult patient in 30s with breast cancer who developed hyperglycemia after receiving pembrolizumab treatment.The patient was diagnosed with diabetic ketoacidosis and further investigations were performed to evaluate for new-onset type 1 diabetes.The patient had a history of hypothyroidism and a family history of breast cancer.Treatment for diabetic ketoacidosis was initiated,and the patient was discharged for close follow-up with an endocrinologist.CONCLUSION This literature review highlights the occurrence of diabetic ketoacidosis and newonset type 1 diabetes in patients receiving pembrolizumab treatment for different types of cancer.Overall,the article emphasizes the therapeutic benefits of immunotherapy in cancer treatment,particularly pembrolizumab,while also highlighting the potential side effect of immune-related diabetes that can occur in a small percentage of patients.Here we present a case where pembrolizumab lead to development of diabetes after a few cycles highlighting one of the rare yet a serious toxicity of the drug.