Tuberculous lymphadenitis presenting with hypercalcemia and acute kidney injury: Diagnostic challenges and management insights: A case report

Tuberculous lymphadenitis, though uncommon, represents an important and potentially underrecognized cause of severe hypercalcemia and associated renal impairment. It underscores the importance of evaluating granulomatous diseases in unexplained hypercalcemia and demonstrates the role of denosumab as an effective adjunct therapy when conventional treatment modalities fail to correct hypercalcemia associated with tuberculosis. This case report of a 69-year-old female who presented with altered sensorium, oliguria, post-traumatic stress disorder (PTSD). Evaluation revealed hypercalcemia and acute kidney injury. Imaging showed extensive retroperitoneal lymphadenopathy, raising suspicion of a granulomatous disorder. Denosumab (120 mg IV) was administered alongside modified anti-tuberculosis therapy (ATT), resulting in normalization of serum calcium levels, renal function recovery, and resolution of neurological symptoms. Tuberculous lymphadenitis may present with severe hypercalcemia and acute kidney injury, mimicking neuropsychiatric conditions. Accurate diagnosis requires biochemical, radiological, and microbiological evaluation. While anti-tuberculosis therapy (ATT) is primary, denosumab is effective for hypercalcemia management in renal dysfunction. Early recognition and targeted treatment are crucial for optimal patient outcomes. This case emphasizes the need to consider granulomatous diseases like tuberculosis in the differential diagnosis of unexplained hypercalcemia with renal dysfunction. Denosumab serves as a safe and effective therapeutic option for managing severe hypercalcemia, especially in patients with contraindications to bisphosphonates due to renal impairment.