title: Autoimmune hypocalciuric hypercalcemia unresponsive to glucocorticoid therapy in a patient with blocking autoantibodies against the calcium-sensing receptor.
abstract: BACKGROUND
  Autoantibodies directed against the calcium-sensing receptor (CaSR) have been reported in several individuals with various autoimmune disorders and PTH-mediated hypercalcemia. Previously, glucocorticoid treatment has been shown to decrease the CaSR autoantibody titers and normalize the hypercalcemia in a patient with autoimmune hypocalciuric hypercalcemia (AHH).
  
  
  OBJECTIVE
  The objective of the study was to evaluate a patient with AHH for the presence of blocking autoantibodies against the CaSR and to monitor her biochemical and serological responses to a trial of glucocorticoid therapy.
  
  
  RESULTS
  Glucocorticoid treatment had no effect on serum total or ionized calcium concentration or serum PTH levels, all of which remained at higher than normal levels. In contrast, on prednisone, urinary calcium excretion increased from overtly hypocalciuric levels to normal values. Anti-CaSR autoantibodies were detected at similar levels in the patient's serum before, during, and after glucocorticoid treatment. Functional testing of these antibodies showed that they inhibited the stimulatory effect of extracellular Ca(2+) on ERK1/2 but did not suppress the calcium-induced accumulation of inositol-1-phosphate.
  
  
  CONCLUSIONS
  We report a patient with AHH with frankly elevated PTH levels who was found to have autoantibodies against the CaSR. The hypercalcemia and CaSR autoantibody titers failed to respond to glucocorticoid therapy, unlike a previously reported patient with similar clinical and biochemical features. The anti-CaSR antibody-mediated inhibition of CaSR-stimulated ERK1/2 activity, but not of inositol-1-phosphate accumulation, suggests that ERK1/2 may mediate, at least in part, the regulation of PTH secretion and urinary calcium excretion by the CaSR.
authors.affiliation: Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA. jpallais@partners.org
authors.forename: J Carl
authors.initials: JC
authors.lastname: Pallais
authors.forename: E Helen
authors.initials: EH
authors.lastname: Kemp
authors.forename: Clemens
authors.initials: C
authors.lastname: Bergwitz
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Kantham
authors.forename: David M
authors.initials: DM
authors.lastname: Slovik
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Weetman
authors.forename: Edward M
authors.initials: EM
authors.lastname: Brown
mesh_terms: D000368:Aged; D000974:Antibodies, Antinuclear / Q000032:analysis; D019138:Antibodies, Blocking / Q000276:immunology; D001323:Autoantibodies / Q000276:immunology*; D001327:Autoimmune Diseases / Q000188:drug therapy* / Q000276:immunology*; D002118:Calcium / Q000494:pharmacology / Q000652:urine*; D004351:Drug Resistance; D048049:Extracellular Signal-Regulated MAP Kinases / Q000378:metabolism; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use*; D006801:Humans; D006934:Hypercalcemia / Q000188:drug therapy* / Q000276:immunology*; D007073:Immunoglobulin E / Q000097:blood; D047468:Immunoprecipitation; D007295:Inositol Phosphates / Q000378:metabolism; D010281:Parathyroid Hormone / Q000378:metabolism; D010766:Phosphorylation; D044169:Receptors, Calcium-Sensing / Q000037:antagonists & inhibitors* / Q000276:immunology*; D013268:Stimulation, Chemical; D010738:Type C Phospholipases / Q000378:metabolism
chemical_list: D000974:Antibodies, Antinuclear; D019138:Antibodies, Blocking; D001323:Autoantibodies; D005938:Glucocorticoids; D007295:Inositol Phosphates; D010281:Parathyroid Hormone; D044169:Receptors, Calcium-Sensing; D007073:Immunoglobulin E; D048049:Extracellular Signal-Regulated MAP Kinases; D010738:Type C Phospholipases; D002118:Calcium