A 34 years-old male, ex-smoker.

Chronologically:

-About 9 months ago: left loin pain, diagnosed to have renal colic and renal gravels, pain subsided with analgesics

-3 months ago: after lifting an object (display!!) he had a severe backache with left lower limb paraesthesia, also received N.S.A.I.D.s for 1½ month

-He had M.R.I. spine done revealing:

-multiple-level vertebral lesions especially L4 and L5

-right iliac bone lesion postulating a tumor lesion

- He was recommended to consult oncology specialty where he was recommended to have Pan-C.T., but it was hindered by the prior routine labs which revealed an elevated s.creatinine (9.4 mg/dl)

-At this point the patient presented to us with:

-marked pallor, about to collapse

- s.creatinine: 9 mg/dl

-Ca⁺²: 13 mg/dl

-parathormone: 8 (normal: 15 to 65 pg/mL)

-N.B. with rapid conservative measures s.creatinine dropped to      4.5 mg/dl, it was necessary to do so because we considered him to have an emergency hypercalcemia mandating rapid action lest he lose his life.

-At this stage, rapid action is mandatory and my strong impression of this case (also we faced similar cases) is to have a granulomatous process causing all of the above manifestations.

-With the start of steroids, calcium levels dropped markedly reaching (8.3 mg/dl) with marked alleviation of other symptoms. (All Praise to Allah)

-This denotes that this Ca⁺²-abnormality is due to a granulomatous process and not typical of malignancy.

-We hastened this treatment because of severe patient's complaints and guarding against complications like fractures.

-We can describe it as a granulomatous process, most likely sarcoidosis, with metastatic-like lesion!