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Liu B, Xu G, Li H, Lu G, Ning N, Tang Q. Excessive collagen fiber deposition in idiopathic scrotal calcinosis: a case report. BMC Urol 2024; 24:212. [PMID: 39363259 DOI: 10.1186/s12894-024-01601-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 09/23/2024] [Indexed: 10/05/2024] Open
Abstract
BACKGROUND Idiopathic scrotal calcinosis (ISC) is a manifestation of idiopathic calcinosis cutis, and its etiology is still unknown. CASE PRESENTATION We report a 36-year-old patient manifested multiple gradually increasing yellowish-white scrotal nodules with occasional itching and stinging in the past 6 years and was successfully cured via surgical excision. The laboratory test combined with pathological analysis confirmed the diagnosis of ISC. Like pathological calcinosis in other soft tissues, a large amount of collagen fiber deposition was observed around the calcification nodule, suggesting that abnormal collagen fiber deposition might be an important factor leading to idiopathic calcinosis in the scrotum. Moreover, koilocytes, which indicate human papillomavirus (HPV) infection, were also detected around calcified nodules, indicating the potential pathogenic role of HPV infection in ISC. CONCLUSIONS Here, we report that ISC shows abnormal excessive deposition of collagen fibers around calcified nodules, which may be a vital factor contributing to the disease. Furthermore, combined with the literature review, a new pathogenic mechanism of ISC is proposed, and the site specificity of scrotal calcinosis is explained, providing a basis for further exploration of the pathogenic mechanism of ISC.
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Affiliation(s)
- Bo Liu
- Department of Human Anatomy, Histology and Embryology, Fourth Military Medical University, Xi'an, 710032, China
- Department of Urology, Central Theater Air Force Hospital, Datong, 037000, China
| | - Gongquan Xu
- Department of Urology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Hao Li
- Department of Obstetrics and Gynecology, Reproductive Medical Center, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Guocheng Lu
- Department of Ultrasound Diagnostics, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Ning Ning
- Department of Pathology, Northwest Women's and Children's Hospital, Xi'an, 710061, Shaanxi Province, China.
| | - Qisheng Tang
- Department of Urology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China.
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Achieng S, Harris J, Samaranayaka M, Herrick AL. A rare form of calcinosis in patients with systemic sclerosis-myositis overlap: report of four cases. Rheumatol Adv Pract 2024; 8:rkae011. [PMID: 38420189 PMCID: PMC10901148 DOI: 10.1093/rap/rkae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/04/2024] [Indexed: 03/02/2024] Open
Abstract
Objectives Calcinosis is a well-described entity that occurs in patients with systemic sclerosis (SSc) and dermatomyositis (DM). Calcinosis in SSc typically occurs over pressure points and is usually nodular. We present a case series of four patients with SSc with a much rarer, diffuse form of calcinosis to illustrate this poorly recognized pattern of extensive and debilitating disease. Methods Four patients with SSc and extensive calcinosis were identified from patients attending a tertiary rheumatology centre in the preceding 3 years. Their electronic case notes, radiographic images and medical photographs were reviewed. Results All four patients had the diffuse cutaneous subtype of SSc (dcSSc) and additionally a myositis overlap. This was in the context of 102 of 461 (22%) patients with SSc whose clinical details had been recorded in the preceding 3 years having dcSSc. Their ages at diagnosis ranged from 27 to 65 years. Three were female, two were anti-Scl70 antibody positive, and two were anti-PMScl antibody positive. Development of calcinosis occurred between 1 and 6 years after onset of SSc. Plain radiography showed very extensive calcinosis in various sites, distributed in a pattern akin to sheets of calcium-containing deposits in the skin and subcutaneous tissue. Conclusions Although calcinosis is common in SSc, extensive sheet-like calcinosis is very rare. Our experience suggests that when this form of calcinosis does occur, this is in the context of the diffuse cutaneous subtype of disease and with myositis overlap. The four cases described should raise awareness of this unusual and extensive pattern of disease.
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Affiliation(s)
- Sheilla Achieng
- School of Biological Sciences, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
| | - Jonathan Harris
- Department of Radiology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
| | - Muditha Samaranayaka
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
| | - Ariane L Herrick
- School of Biological Sciences, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
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Davuluri S, Lood C, Chung L. Calcinosis in systemic sclerosis. Curr Opin Rheumatol 2023:00002281-990000000-00088. [PMID: 37830924 DOI: 10.1097/bor.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
PURPOSE OF REVIEW To provide updated information on the prevalence, pathogenesis, diagnostics, and therapeutics of calcinosis cutis associated with systemic sclerosis (SSc). RECENT FINDINGS Observational studies show ethnic and geographical differences in the prevalence of calcinosis. In addition to clinical and serological associations, biochemical studies and in-vivo models have attempted to explain theories behind its pathogenesis, including prolonged state of inflammation, mechanical stress, hypoxia, and dysregulation in bone and phosphate metabolism. Long-term use of proton pump inhibitors may increase the risk for calcinosis in SSc. Few single center observational studies have shown mild benefit with minocycline and topical sodium thiosulfate. SUMMARY Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It affects up to 40% of SSc patients and causes significant morbidity. Long disease duration, features of vascular dysfunction, and osteoporosis have been associated with calcinosis. Altered levels of inorganic pyrophosphate and fibroblast growth factor-23 have been implicated in dysregulated phosphate metabolism that may lead to calcinosis in SSc. Plain radiography can help with diagnosis and quantifying the calcinosis burden. Surgical treatment remains the most effective therapy when feasible. At present, no medical therapies have proven efficacy in large randomized controlled trials.
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Affiliation(s)
- Srijana Davuluri
- Stanford School of Medicine, Division of Immunology &Rheumatology, Palo Alto, California
| | - Christian Lood
- University of Washington, Division of Rheumatology, Seattle, Washington
| | - Lorinda Chung
- Stanford School of Medicine & Palo Alto VA Healthcare System, Division of Immunology & Rheumatology, Palo Alto, California, USA
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Leow MKS, Ang J, Bi X, Koh ET, McFarlane C. Alterations in SAMD9, AHSG, FRG2C, and FGFR4 Genes in a Case of Late-Onset Massive Tumoral Calcinosis. AACE Clin Case Rep 2023; 9:153-157. [PMID: 37736313 PMCID: PMC10509374 DOI: 10.1016/j.aace.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/29/2023] [Accepted: 05/05/2023] [Indexed: 09/23/2023] Open
Abstract
Background/Objective Tumoral calcinosis (TC) is a rare, arcane, and debilitating disorder of phosphate metabolism manifesting as hard masses in soft tissues. Primary hyperphosphatemic TC has been shown to be caused by pathogenic variants in the genes encoding FGF23, GALNT3, and KLOTHO. We report a case of massive TC mechanistically associated with phosphatonin resistance associated with heterozygous alterations in the sterile alfa motif domain-containing protein-9 gene (SAMD9), alfa 2-Heremans-Schmid glycoprotein gene (AHSG), FSHD region gene 2-family member-C gene (FRG2C), and fibroblast growth factor receptor-4 gene (FGFR4). Case Report A middle-aged Malay woman with systemic sclerosis presented with painful hard lumps of her axillae, lower limbs, and external genitalia. She was eucalcemic with mild hyperphosphatemia associated with reduced urinary phosphate excretion. Magnetic resonance imaging revealed calcified soft tissue masses. Paradoxically, the serum intact FGF23 level increased to 89.6 pg/mL, corroborated by Western blots, which also showed overexpression of sFRP4 and MEPE, consistent with phosphatonin resistance. Discussion Whole genome sequencing identified 2 heterozygous alterations (p.A454T and p.T479M) in SAMD9, 2 heterozygous alterations (p.M248T and p.S256T) in AHSG, a frameshift alteration (p.Arg156fs) in FRG2C, and a heterozygous alteration (p.G388R) in FGFR4, all of which are associated with calcinosis. Nonsynonymous alterations of FRP4 and MEPE were also detected. Conclusion This highlights that the simultaneous occurrence of alterations in several genes critical in phosphate homeostasis may trigger massive TC despite their heterozygosity. These findings should prompt functional studies in cell and animal models to reveal mechanistic insights in the pathogenesis of such crippling mineralization disorders.
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Affiliation(s)
- Melvin Khee Shing Leow
- Singapore Institute for Clinical Sciences (A∗STAR), Brenner Centre for Molecular Medicine, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-NUS Medical School, Singapore
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore
| | - Joshur Ang
- Singapore Institute for Clinical Sciences (A∗STAR), Brenner Centre for Molecular Medicine, Singapore
| | - Xinyan Bi
- Singapore Institute of Food and Biotechnology Innovation (A∗STAR), Singapore
| | - Ee Tzun Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Craig McFarlane
- Department of Molecular & Cell Biology, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
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Zhou Y, Chen Y, Yin G, Xie Q. Calciphylaxis and its co-occurrence with connective tissue diseases. Int Wound J 2023; 20:1316-1327. [PMID: 36274216 PMCID: PMC10031236 DOI: 10.1111/iwj.13972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 03/23/2023] Open
Abstract
Calciphylaxis, also known as calcific uremic arteriopathy, is a rare calcification syndrome that presents as ischemic skin necrosis and severe pain. It has a high mortality rate and is characterised by calcification of the small and medium arteries and micro-thrombosis. Calciphylaxis mainly occurs in patients with end-stage renal disease. In recent years, there have been an increasing number of cases of calciphylaxis associated with connective tissue diseases. Given the absence of clear diagnostic criteria for calciphylaxis thus far, an early diagnosis is crucial for designing an effective multidisciplinary treatment plan. In this article, we review the research progress on calciphylaxis and describe its characteristics in the context of connective tissue diseases.
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Affiliation(s)
- Yueyuan Zhou
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuehong Chen
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Geng Yin
- Department of General Practice, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
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Hughes M, Herrick AL. Diagnosis and management of systemic sclerosis-related calcinosis. Expert Rev Clin Immunol 2023; 19:45-54. [PMID: 36333952 DOI: 10.1080/1744666x.2023.2144835] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Calcinosis is common in patients with systemic sclerosis (SSc) and refers to the sub-epidermal deposition of calcium salts in the skin. SSc-related calcinosis is associated with significant morbidity, including through cutaneous ulceration and predisposition to become infected. AREAS COVERED After briefly addressing aetiopathogenesis, we describe the clinical burden of SSc-associated calcinosis and provide a structured and practical clinical approach to diagnosis and assessment, including discussion of the role of different imaging modalities. The multi-faceted treatment of SSc-associated calcinosis is presented under three broad headings of 'general measures,' and 'medical treatment' and 'surgical treatment.' We adopted a narrative approach to identify relevant manuscripts to inform our review. EXPERT OPINION SSc-related calcinosis is an area of major unmet clinical need and for too long has been a neglected area of research. Safe and effective treatments are badly needed to improve patient quality of life and outcomes. To facilitate future clinical trials, we require increased understanding of pathogenesis (to inform selection of potential targeted therapies) and reliable outcome measures, including those which will measure the impact and severity of calcinosis from the patient perspective. International collaborative research is ongoing to develop outcome measures and treatments for this potentially devastating complication of SSc.
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Affiliation(s)
- Michael Hughes
- Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide updated information on the prevalence, pathogenesis, diagnostics and therapeutics of calcinosis cutis associated with systemic sclerosis (SSc). RECENT FINDINGS Observational studies show ethnic and geographical differences in the prevalence of calcinosis. In addition to clinical and serological associations, biochemical studies and in-vivo models have attempted to explain theories behind its pathogenesis, including prolonged state of inflammation, mechanical stress, hypoxia and dysregulation in bone and phosphate metabolism. Long-term use of proton pump inhibitors may increase the risk for calcinosis in SSc. Few single-centre observational studies have shown mild benefit with minocycline and topical sodium thiosulfate. SUMMARY Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It affects up to 40% of SSc patients and causes significant morbidity. Long disease duration, features of vascular dysfunction and osteoporosis have been associated with calcinosis. Altered levels of inorganic pyrophosphate and fibroblast growth factor-23 have been implicated in dysregulated phosphate metabolism that may lead to calcinosis in SSc. Plain radiography can help with diagnosis and quantifying the calcinosis burden. Surgical treatment remains the most effective therapy when feasible. At present, no medical therapies have proven efficacy in large randomized controlled trials.
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Affiliation(s)
- Srijana Davuluri
- Stanford School of Medicine, Division of Immunology & Rheumatology, Palo Alto, California
| | - Christian Lood
- University of Washington, Division of Rheumatology, Seattle, Washington
| | - Lorinda Chung
- Stanford School of Medicine & Palo Alto VA Healthcare System, Division of Immunology & Rheumatology, Palo Alto, California, USA
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Memida T, Matsuda S, Nakamoto T, Ouhara K, Kajiya M, Hirata S, Sugiyama E, Kakimoto N, Mizuno N. Cancellous bone-like tissue replacement from calcinosis in patients with systemic sclerosis with multiple external root resorption. Bone Rep 2022; 16:101165. [PMID: 35059476 PMCID: PMC8760497 DOI: 10.1016/j.bonr.2021.101165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/27/2021] [Accepted: 12/31/2021] [Indexed: 12/24/2022] Open
Abstract
Calcinosis is frequently observed in patients with systemic sclerosis (SSc). The fundamental treatment of calcinosis has not yet been established. During follow-up, calcinosis in the subcutaneous surface is often spontaneously extracted or remains confined by fibrous tissues. We previously identified a new symptom in SSc patients, multiple external root resorption (MERR), and these patients had calcifications in the nasal spine. Here, we report for the first time that calcinosis at the nasal spine in patients with MERR can be replaced by cancellous bone-like tissue. Patients 1 and 2 were a 62-year-old Japanese female and a 45-year-old Japanese female (respectively) with MERR who had been previously treated for SSc (Patient 1: limited type, positive for anti-centromere antibody; Patient 2: diffuse type, positive for anti-Scl70 and anti-SS-A antibodies). Patient 3 was a 57-year-old female with MERR who had been previously treated for SSc (diffuse type, positive anti-Scl-70 antibody) and underwent denosumab injection for osteoporosis. Cone-beam computed tomography (CBCT) and CT images in the calcifications at the nasal spine in Patient 1 and 2 were replaced with cancellous bone-like tissue, but not in Patient 3. Serum laboratory examination was performed to assess the systemic bone disease. All three patients had normal clinical data within the references, apart from slightly higher 1,25-dihydroxyvitamin D levels in Patient 1. SSc patients with calcinosis in the maxillofacial area need to be examined carefully for bone replacement using CBCT or CT.
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Chiu H, Trudel G. Popcorn universalis. BMJ : BRITISH MEDICAL JOURNAL 2022. [DOI: 10.1136/bmj-2021-068294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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