Fatigue, Weight Loss, Granuloma, High Vit. D 1,25, High Calcium

Dr.
Can you help with my issue as outlined below:

37 YR. Male, healthy until a year ago.  156 lbs (20 pounds lost in year).  5' 10"  

Symptom overview:  Shortness of breath, fatigue, cough, neurological issues (speech, short term memory) congestion, dizziness/faitness for over year.  ENDO noted to look at Lymphoma due to High Vit. D 1.25 and high calcium.

Labs:  
MRI:  Periventricular white matter hyperintensities in left occipital lobe.
Chest CT w/o contrast:  Calcified Granulomas in the posterior right upper lobe and liver.  
Vitamin D 1,25 68 (High)
Vtamin D 25, 58 (normal)
Calcium (10.8) (High).  Calcium high for past year (10-11.1)
Normal Parathyroid function
ACE: 30 (normal)
TB PTT skin test:  Normal
Lymphocytes decreasing over past year (28 down to 15)
Granulytes increasing over past year (59 to 70)
WBC increasing over past year (7 to 10.8)
Occassional dip in IGG below normal
C4 complement (consistently low at 15)
Pulmonary FVC 88% of predicted
Pulmonary FEV1 85% of predicted
Deficient response to Pneumonia vacine on 10 of 13 types.
Albumin percentage borderline high (71) with high-normal absolute Albumin (5.4)
Sed Rate:  5
HIV:  Negative

Unlikely based on additional labs: (MS, most autoimmune diseases)

Questions:
1)  What other diagnosis/tests would you recommend?  Lymphoma?  Fungal?  Which tests?

2)  Can you read a calcified granuloma like active granulomas to determine the type of disease or do they lose their signifgance once calcified.

3)  Is the TB skin test reliable?

4)  I've read that high Vit D 1,25 is almost always signifigant, indicating either inflamation (inflammation) or extra-renal production of 1,25 from a granuloma activity.???  (Parathryroid function okay so that is not causing the problem with the excess 1,25 production)

5)  Would a CT with contrast pick up active granulomas or is the CT I did w/o contrast sufficient?



Thank you!
Marc

[PaulMD]

Hi there.

The art and science of diagnosing a disease should first start with a good history, physical examination, and a preliminary clinical impression that should prompt the doctor to request tests to strengthen his or her impression.  From what you have outlined, it seems that a shot gun approach is being employed which I think is not a very effective way to handle things.  You and your doctors would end up doing all the labs and tests which when abnormal, will lead to more tests which does not really explain or tell us much.  

However, to answer your questions:  The TB skin test only signifies TB exposure if positive and not tantamount to infection.  A possible test to differentiate an active or non active granuloma is a PET scan.  Contrast CT scan cannot tell whether granulomas are active or not.

I suggest that you request your doctors to present your case in a multidisciplinary conference to have the inputs of several specialists.  

Regards.