Dermatomyositis and calcific myonecrosis in the leg: ultrasound as an aid in management

Calcific Myonecrosis of the Leg: A Rare Entity

Calcific myonecrosis is a rare disease that has been shown to be a late sequela of trauma. This article presents a 68-year-old man with calcific myonecrosis of the leg 40 years after a tibial fracture complicated with peroneal nerve palsy. The soft tissue mass increased in size after another injury to the leg that occurred two years before his presentation. Physical examination at presentation showed a palpable extra-osseous mass at the anterior aspect of the left leg; the mass was not adherent to adjacent soft-tissues and bone, and it was painless but tender to palpation. Radiographs of the left leg showed extensive calcification at the soft-tissue of the anterior and posterior leg. An ultrasonography-guided trocar biopsy was done; histological findings were indicative of calcific myonecrosis. Given the benign entity of the lesion and known high rate of complications, he was recommended for no further treatment except for clinical and imaging observation. Located at the site of the biopsy, he experienced infection with drainage that eventually healed after six months with antibiotics and wound dressing changes. During the last follow-up examination, two years after diagnosis, the patient was asymptomatic without progression of the mass.

Management of calcific myonecrosis with a sinus tract: A case report

RATIONALE

Calcific myonecrosis is a very rare late sequela that occurs in patients who have had trauma accompanied by vascular compromise, in which a single muscle or entire muscles in a compartment undergoes necrosis and form a calcified mass. It is mostly a benign entity, but some cases cause bone destruction and form non-healing chronic sinuses. In such cases, wound management becomes difficult and there is a potential risk of secondary infection.

PATIENT CONCERNS

A 60-year-old male was referred for evaluation of a pain, erythematous changes, and draining sinus of the anterolateral aspect of his left leg. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery owing to a distal femur fracture and femoral artery rupture.

DIAGNOSES

A thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The radiographs of the left leg showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula. We performed an incisional biopsy to differentiated soft tissue sarcoma and malignant cells were found. Pathologic evaluation revealed acute and chronic inflammation with dystrophic calcification. These findings led to the diagnosis of calcific myonecrosis.

INTERVENTIONS

We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Upon performing extensive debridement, we inserted a drain tube and performed primary closure.

OUTCOMES

The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred 4 weeks following the surgery, and there was no recurrence at follow-up conducted 2 years later.

LESSONS

Calcific myonecrosis is mostly a benign entity, but some cases of calcific myonecrosis cause bone destruction and form non-healing chronic sinuses. In such cases, surgical treatment is required, during which the necrotic tissue and calcific material must be extensively debrided and drained.

Calcific myonecrosis mimicking soft tissue sarcoma: A case report

Calcific myonecrosis is a rare soft tissue condition. The first case was reported in 1960, however, the precise pathophysiology of calcific myonecrosis remains unclear. The disease was thought to arise from compartment syndrome within a confined space resulting in necrosis and fibrosis, subsequent repeated intralesional hemorrhage, mass enlargement and calcification. Several previous reports have described calcific myonecrosis, which include the formation of calcific myonecrosis after a prolonged period of post trauma. Notably, calcific myonecrosis has typically been described in the lower legs and characteristic imaging findings have been indicated. Furthermore, surgical intervention carries a high risk of complications. In the present case report 2 cases of calcific myonecrosis that occurred after a prolonged period of time following a traumatic event that impacted the lower leg were reported. CT images revealed disruption of calcified fascia and disease expansion into the outside of the fascia. Previous reports have implied that there is late focal enlargement of calcific myonecrosis following earlier enlargement, which may be caused by herniation through muscle fascia. However, no previous publications have focused on images for evidence of late local enlargement. To the best of our knowledge, this is the first report focusing on fascial herniation of calcific myonecrosis using images. Analysis of this feature using images may aid clinicians to differentiate calcific myonecrosis from malignancies.

Calcific myonecrosis: diagnostic dilemma

Calcific myonecrosis is a rare benign condition affecting mainly the muscles of a single leg compartment. It is thought to follow a history of trauma with a latent period of years. Patients present with a slowly growing mass. Differential diagnosis from a malignant tumour can be made from the history and the distinctive radiographical features of a fusiform lesion with predominantly peripheral calcifications. Magnetic resonance imaging may be necessary to confirm the diagnosis; treatment is largely symptomatic.

Calcific myonecrosis following snake bite: a case report and review of the literature

Introduction

Calcific myonecrosis is a rare condition in which muscle in a limb compartment undergoes necrosis and becomes peripherally calcified with central liquefaction. The patient usually presents with a slowly progressive enlarged mass that sometimes can be misdiagnosed as soft tissue sarcoma. Most of the reported cases showed that the disease occurs often after trauma or compartment syndrome. However, the case of calcific myonecrosis following snake bite is rarely reported.

Case presentation

A 66-year-old Thai woman presented with a gradually progressive enlarged mass over a period of 10 years in her left leg. She had a history of untreated compartment syndrome after she was bitten by a snake (Malayan pit viper) in her left leg when she was 14-years old. At presentation, a plain X-ray showed a large soft tissue mass at the anterior compartment of her left leg. A sheet-like mass with an enlarged central cavity combined with peripheral calcification and cortical erosion of her tibia were observed. A biopsy was performed and the result was negative for neoplastic cells. During a 5-year follow-up, the mass progressively enlarged and then became infected and finally broke through the skin. She was treated by excision of the mass and administration of antibiotics. The wound completed healed at 1 month postsurgery. There was no wound complication or disease recurrence at 1 year postoperation.

Conclusions

The diagnosis of calcific myonecrosis was done by history taking and radiographic interpretation. In an asymptomatic patient the management should be observation and clinical follow-up. A biopsy should be avoided due to the high rate of postoperative infection. Treatment of choice in a symptomatic condition is mass excision.

Calcific myonecrosis: a case report and review of the literature

Calcific myonecrosis is a rare post-traumatic sequel of the lower limb, presenting in a delayed manner several years after the initial injury. We report a case of a 43-year-old gentleman who presented emergently with an enlarging painful mass in the lateral side of his left leg, that although present for several years had recently worsened with respect to the pain and erythema. Following laboratory and radiological investigations this was diagnosed to be calcific myonecrosis, which was then treated conservatively, and patient discharged when symptomatically improved.

Calcific myonecrosis of the upper extremity: case report

Calcific myonecrosis is an uncommon late sequela of limb trauma that results in calcification and necrosis of damaged muscle. It almost exclusively occurs in the lower extremity. We present a second case of calcific myonecrosis in the upper extremity.

Ultrasound in the evaluation of the inflammatory myopathies

The lack of precise measures of disease activity may complicate the care of patients with inflammatory myopathies (IM). Techniques currently available to physicians in practice rely on measurement of function, strength, laboratory indices, muscle biopsy, and imaging techniques. Although MRI has become the method of choice to assess IM, it is expensive, difficult for some patients to tolerate, and contraindicated in those with pacemakers, aneurysm clips, and other ferromagnetic biomedical implants. Ultrasonography is an alternative approach to image the muscular system. Newer applications of ultrasound, such as power Doppler sonography (PDS), contrast-enhanced ultrasound, and sonoelastography, show some promising results in further characterizing normal and pathologic states. Technical improvements, including extended field-of-view, compound imaging, and harmonic imaging, further enhance one's ability to display changes in muscle morphology. This article reviews the sonographic appearances of normal and pathologic muscle with respect to inflammatory myopathies.

[Imaging techniques and electromyography in inflammatory myopathies]

Different imaging techniques are used for the diagnosis, evaluation and follow-up of inflammatory myopathies; of these techniques, the ones that provide the largest amount of information are ultrasonography and magnetic resonance imaging. Electrodiagnosis in inflammatory myopathies is based mainly on electromyography (EMG), which shows different patterns according to the different disease presentations. In the acute phase, polyphasic potentials with diminished amplitude and duration are seen, whereas in its chronic phases, mixed neuropathic and myopathic patterns are found. After corticosteroid treatment, EMG tends to return to normal.

Calcific myonecrosis of the lower leg: diagnosis and options of treatment

INTRODUCTION

Calcific myonecrosis is a rare condition characterized by a calcified lesion. Because this lesion sometimes presents as a huge mass with unique radiographic characteristics, it can be confused with soft tissue sarcoma. The appropriate treatment is still controversial. We report here three cases diagnosed as calcific myonecrosis of the lower leg and discuss its clinical presentation, diagnosis and options for treatment.

PATIENTS AND METHODS

Three patients presented as expanding masses in the anterior or lateral compartment muscle and occurred more than 10 years after an initial injury. Plain radiographs showed a large soft tissue mass with extensive amorphous calcifications. Computed tomograms revealed a low-density tumor with scattered calcifications. Magnetic resonance imaging showed a bright, high-signal area on T2-weighted imaging consistent with fluid. Two patients underwent excisions for histopathological evaluation and one was treated conservatively because of the absence of disability.

RESULTS

Two operative patients had no complication and the returned to work without evidence of deterioration of the disease. In a patient treated conservatively, the mass was not enlarged and was still painless at 2-year follow-up.

CONCLUSION

The key points for diagnosis were (1) amorphous liner calcification, (2) anterior or lateral compartment, (3) previous injury (several decades) of the tibia or femur, and (4) compartment syndrome. Although calcific myonecrosis is not commonly encountered, it must be considered in the differential diagnosis of an expanding intramuscular mass. In asymptomatic masses where the diagnosis is recognized, observation may be possible and unnecessary aggressive surgical intervention should be avoided.

[Optimized negative pressure therapy. Case report]

Our patient showed major abdominal cutaneous necrosis. Detersion removed the entire thickness of half of the right-hand wall of the abdomen. We are going to explain how, by combining well known procedures, we conducted this closure. This deals with a patient aged 53, with a long case history of dermatomyositis and highly debilitating sub-cutaneous calcinosis. This patient has been treated with Imurel and high doses of corticoids since 1997. In the face of the much debilitated terrain of the patient, it was not certain that a local flap or even a pediculated flap could be made to cover this loss of substance with a minimum of risk. A cutaneous extension was then envisaged using a system of Wisebands fillets. To protect the parietal plate, accelerate its growth and reduce the skin tension, we used in combination a system of foam dressing with negative pressure therapy (NPT). The optimized NPT was used for 2 weeks. The Wisebands were installed for 1 month. The treatment lasted for 50 days and required five short sessions of general anaesthesia. The histopathological interpretation revealed an EBV lymphoma. The assessment of the extension and the therapeutic treatment of the lymphoma contributed to the duration of hospitalisation and the number of general anaesthesia sessions. The synergy effect of these two associated procedures have allowed a faster skin closure; 18 months later, no complications have occurred. The wound has closed totally and the abdominal wall is solid in spite of not having resorted to a flap or separation.

Calcific myonecrosis and the role of imaging in the diagnosis: a case report

Calcific myonecrosis is a rare posttraumatic complication characterized by the replacement of muscles of one or more compartments with central liquefaction and peripheral calcification. We report magnetic resonance imaging (MRI) and CT imaging features of calcific myonecrosis arising 43 years after trauma. A 62-year-old man presented with a slowly enlarging mass in the left lower leg. Plain radiographs revealed a soft tissue mass with extensive amorphous calcification. The middle third of the tibia and fibula were eroded. MRI demonstrated peripheral ring enhancement on postcontrast fat-suppressed T1-weighted images. Volume-rendered images extracting only the images of bone and vessels also showed many branches from the tibialis posterior and peroneal arteries around the bone defect. During the operation, bleeding continued heavily from the vessels penetrating the cortical bone of the tibia, from the posterior compartment, and from the branches of tibialis posterior artery. The total blood loss was approximately 2,400 milliliters. There may be a causal relationship between massive bleeding and the hypervascularity of this tumor as evidenced by MRI and volume-rendering CT studies.

Calcific myonecrosis and tenosynovitis: sonographic findings with correlative imaging

We report the sonographic appearance of a case of calcific myonecrosis and tenosynovitis with correlative plain radiography and CT findings. Calcific myonecrosis is a rare complication of previous trauma that presents as a tumor-like calcified mass years after an initial injury, most commonly affecting the anterior compartment of the lower leg. Although the clinical, radiographic, and MRI features of calcific myonecrosis have been well described, to our knowledge the sonographic appearance has not been reported previously in the literature.