Nephrology: granulomatous hypercalcaemia: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Nephrology: granulomatous hypercalcaemia

Sample item

A 34-year-old woman has bilateral hilar lymphadenopathy, thirst and polyuria. Serum calcium is 12.9 mg/dL, intact PTH is suppressed, 25-hydroxyvitamin D is normal and 1,25-dihydroxyvitamin D is raised. What is the most appropriate therapy?

ACinacalcetBOral glucocorticoidsCParathyroidectomyDVitamin D supplements to correct the deficiency

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

B. Oral glucocorticoids

In sarcoidosis, activated macrophages in granulomas express 1-alpha-hydroxylase and convert 25-hydroxyvitamin D to calcitriol without feedback regulation, causing hypercalcaemia and hypercalciuria with a suppressed PTH. Glucocorticoids inhibit this macrophage enzyme activity and are the treatment of choice. Dietary calcium and sun exposure should be limited.

Option by option

A. Cinacalcet
Cinacalcet lowers PTH, which is already suppressed, so it does not address the calcitriol excess.
B. Oral glucocorticoids (correct)
Correct. Steroids suppress macrophage calcitriol production, which is the cause of the hypercalcaemia.
C. Parathyroidectomy
Parathyroidectomy treats primary hyperparathyroidism, but PTH here is suppressed.
D. Vitamin D supplements to correct the deficiency
Vitamin D is not deficient and giving more would worsen the hypercalcaemia.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is B, Oral glucocorticoids. In sarcoidosis, activated macrophages in granulomas express 1-alpha-hydroxylase and convert 25-hydroxyvitamin D to calcitriol without feedback regulation, causing hypercalcaemia and hypercalciuria with a suppressed PTH.

Why is "Cinacalcet" not the answer?

Cinacalcet lowers PTH, which is already suppressed, so it does not address the calcitriol excess.

Why is "Parathyroidectomy" not the answer?

Parathyroidectomy treats primary hyperparathyroidism, but PTH here is suppressed.

Why is "Vitamin D supplements to correct the deficiency" not the answer?

Vitamin D is not deficient and giving more would worsen the hypercalcaemia.

What concept does this question test?

It tests Nephrology: granulomatous hypercalcaemia in General Medicine. Glucocorticoids inhibit this macrophage enzyme activity and are the treatment of choice. Dietary calcium and sun exposure should be limited.

How hard is this question?

We tag it as an application question: it asks you to use a fact on a patient or a finding. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Nephrology: granulomatous hypercalcaemia?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.