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

Masseter idiopathic calcinosis circumscripta: A rare condition

Calcinosis is defined as a biomineralization occurring in soft tissues leading to ectopic calcification. Isolated and localised calcification in a muscle is rare, and it is called calcinosis circumscripta in opposition to calcinosis universalis wich is seen in juvenile dermatomyositis and polymyositis. According to laboratory findings and clinical history, calcinosis circumscripta can be metastatic, dystrophic or idiopathic. Masseter muscle is rarely involved. Pre-operative diagnosis of masseter idiopathic calcinosis is a challenge because of many differential diagnosis. Here, we report a case of 22 years old women presented with swelling over left middle third of her face. Clinical history, morphologic and laboratory examinations helped considering such a rare diagnosis.

Calcific Myonecrosis: Solving the Diagnostic Dilemma

We report the clinico radiological presentation of an unusual case of an ossified soft tissue mass in the leg in a 74-year-old man. Calcific myonecrosis is a rare soft tissue condition characterized by calcified mass within a compartment. Differential diagnosis of myonecrosis include myositis ossificans and sarcomas with propensity for extra-osseous calcification like extra-skeletal osteosarcoma, Ewing's sarcoma and epithelioid sarcoma. This entity is a late complication to trauma and prolonged high pressure state within the leg compartments. With imaging alone, the differential of soft tissue sarcoma could be ruled out but typical natural history of disease and radiopathological features aided in the diagnosis.

Treatment of infected calcific myonecrosis with chronically discharging sinus caused by iatrogenic aspiration: A case report

Introduction and importance

Calcific myonecrosis (CM) is a rare, benign post-traumatic sequela which is often challenging to differentiate from soft tissue tumors. Infected CM is recalcitrant and sometimes requires invasive treatment despite its benign nature. We present a case of infected CM in which MRI and ²⁰¹Tl scintigraphy proved useful for diagnosis and intralesional debridement with prolonged placement of a suction tube allowed for successful treatment.

Case presentation

A 71-year-old man had undergone repeated aspiration for swelling of the lower leg and presented with a sustained pyogenic discharging wound. He underwent intralesional debridement of purulent necrotic tissue followed by prolonged suction tube placement. Enterobacter cloacae was detected in the discharge, and specific antibiotics were administered. Once the wound closed, a new sinus recurred four months after surgery, warranting reoperation with debridement of the remnant fascia and necrotic tissue with suction tube replacement. The wound healed eight months after the first surgery with no signs of recurrence.

Clinical discussion

CM can be diagnosed based on its unique imaging features and a history of compartment syndrome. To avoid infection, CM must be treated conservatively without surgical invasions, such as biopsy or aspiration. Extensive debridement with a myocutaneous flap is nevertheless recommended for infected CM treatment, despite significant invasion including intraoperative bleeding being problematic.

Conclusion

MRI and ²⁰¹Tl scintigraphy can help diagnose CM and avoid biopsy to exclude malignancy. Intralesional debridement of necrotic tissue with prolonged suction tube placement could be a valid treatment alternative to reduce the invasiveness of infected CM.

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Calcific myonecrosis is a rare, benign posttraumatic sequela.

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Biopsy to differentiate malignancy can cause calcific myonecrosis.

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Absence of accumulation on enhanced MRI or ²⁰¹Tl scintigraphy helped diagnosis.

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Extensive debridement and flaps are reliable but invasive in case of infection.

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Intralesional debridement with prolonged tube placement may be less invasive.

Traumatic calcific myonecrosis with abscess and outflow of sequestrum: A case report

Calcific myonecrosis (CM) is a rare benign long-term complication secondary to trauma, especially when trauma is combined with neurovascular injury or osteofascial compartment syndrome. CM frequently manifests as an asymptomatic mass and the anterior tibial area is the most common site, which is apt to be misdiagnosed as a bone tumor. In addition, even if the diagnosis is clear, the therapy is controversial because some authors suggested regular follow-up could replace surgery. However, patients with CM are prone to infection. Under such conditions, infection is hard to be controlled and non-surgical therapy will provide the limited effect. Here we reported a rare and interesting case about a patient diagnosed with calcific myonecrosis in our hospital. Imaging presented typical and impressive features of CM in his left leg. Besides, the patient suffered severe infection and antibiotics played a limited role. Subsequently, the abscess formed and the incision is unhealed after abscess incision drainage with the lasting outflow of pus and sequestrum. Finally, surgery was conducted and we found his anterior tibial muscle was replaced by osteoid and necrotic tissues. Postoperative pathology identified traumatic tumoral calcinosis. This patient now has no evidence of recurrence, with a follow-up of 22 months.

Extensive calcific myonecrosis of the lower leg treated with free tissue transfer

Calcific myonecrosis is a rare condition in which hypoperfusion due to compartment syndrome causes soft tissue and muscle to become calcified. As calcific myonecrosis gradually deteriorates, secretions steadily accumulate inside the affected area, forming a cavity that is vulnerable to infection. Most such cases progress to chronic wounds that are unlikely to heal spontaneously. After removing the calcified tissue, the wound can be treated by primary closure, flap coverage, or a skin graft. In this case, a 72-year-old man had extensive calcific myonecrosis on his left lower leg, and experienced swelling and increasing tenderness. After removing the muscle calcification, we combined two anterolateral thigh free flaps, which were harvested from the patient's right and left thigh, respectively, to reconstruct the wound with a dead-space filler and skin-defect cover at the same time. The patient recovered without revision surgery or major complications.

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.

Calcific Myonecrosis of the Leg: A Case Report

Calcific myonecrosis is characterized by central liquefaction and peripheral calcification involving the entire muscle mass and is considered to be a late sequel of compartment syndrome. Being a rare presentation, considering differential diagnosis is important. Diagnosis is based on history of trauma and typical radiological features. Symptomatic patients require complete excision of the mass while asymptomatic patients can be treated nonoperatively.

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.

Transient Heterotopic Calcification and Unexpected Hypercalcemia after Treatment of Septic Shock

Transient heterotopic calcification with unexpected hypercalcemia after septic shock is a very rare phenomenon. We encountered a complicated case in which heterotopic calcification occurred in the liver, bilateral iliopsoas and pubococcygeal muscles after treatment of septic shock and multiple organ failure. Hypercalcemia was not present when the heterotopic calcification was detected by plain CT scans. Physicians who observe acute and progressive heterotopic calcification during sepsis treatment need to recognize the risk of hypercalcemia even if it is not present before the detection of heterotopic calcification. This case provides useful information regarding the critical aspects of heterotopic calcification after sepsis treatment.

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 two-patient case series

Calcific myonecrosis is a rare entity with only 57 cases reported in the English literature to date. It is a late complication of compartment syndrome of the limb and results in characteristic muscle necrosis with central liquefaction and peripheral calcification. This series presents a further two cases and consolidates the diagnostic features and treatment modalities described in the literature.

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.

A unique case of dystrophic calcification in masseter: a diagnostic challenge

The objective of this study was to present an unusual case of isolated dystrophic calcification in masseter and the diagnostic challenge it posed. A case report on a 14-year-old boy presented with swelling in left parotid region along with the review of literature was reported. Histopathological and biochemical analyses of the excised mass diagnosed this affliction as dystrophic calcification. Dystrophic calcification is deposition of calcium salt in degenerated tissues in the presence of normal calcium and phosphorous metabolism. It usually occurs in injured tissues. This is different from systemic mineral imbalance causing metastatic calcification and needs to be differentiated. On reviewing the literature, this appears to be the second reported case in the world wide literature. The unique presentation, diagnosis, and surgical management of dystrophic calcification have been described.