Pseudoxanthoma elasticum (PXE)-like calcification in adult dermatomyositis

Calcinosis Cutis and Calciphylaxis in Autoimmune Connective Tissue Diseases

Calcinosis represents a severe complication of several autoimmune disorders. Soft-tissue calcifications have been classified into five major types: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. Autoimmune diseases are usually associated with dystrophic calcifications, including calcinosis cutis, occurring in damaged or devitalized tissues in the presence of normal serum levels of calcium and phosphate. In particular, calcinosis cutis has been described in dermatomyositis, polymyositis, juvenile dermatomyositis, systemic sclerosis, systemic lupus erythematosus, primary Sjögren's syndrome, overlap syndrome, mixed connective tissue disease, and rheumatoid arthritis. Calciphylaxis, a severe and life-threatening syndrome presenting with vascular calcifications and thrombosis, has also been associated with some autoimmune conditions. Due to the potentially disabling character of calcinosis cutis and calciphylaxis, physicians' awareness about the clinical presentation and management of these diseases should be increased to select the most appropriate treatment option and avoid long-term complications. In this review, we aim to analyze the clinical features of calcinosis cutis and calciphylaxis associated with autoimmune diseases, and the main treatment strategies evaluated up to now for treating this potentially disabling disease.

Lipodermatosclerosis: a clinicopathological study of 25 cases

BACKGROUND

Lipodermatosclerosis is a chronic fibrosing process that involves both lower legs and classically affects Caucasian women in their 60s.

OBJECTIVE

The objective is to define the histologic spectrum seen this condition.

METHODS

A total of 25 cases were collected prospectively and all were stained with hematoxylin-eosin, von Kossa, and Verhoeff-van Gieson.

RESULTS

Patient age ranged from 33 to 84 years (mean age 62.6 years). The female to male ratio was approximately 12 to 1. All lesions were present on the lower extremities, between the knee and ankle. Lesion duration ranged from 2 months to 2 years (mean 9.5 months). Clinically, the lesions were erythematous, tender, indurated plaques or nodules. The characteristic histologic findings were seen almost exclusively in the subcutaneous tissue, involving primarily the lobules but also the septa. Adipose changes included micropseudocyst and macropseudocyst formation, necrotic adipocytes, lipomembranous change, and lipogranulomas with xanthomatous macrophages. The lesions were largely devoid of dermal, septal, or lobular neutrophilic or lymphocytic inflammation. Medium vessel calcification was seen in 13 cases. The accumulation of basophilic elastic fibers located deep in the septa was present in all the cases. These fibers had a moth-eaten appearance and resembled pseudoxanthoma elasticum. In 21 of 25 cases, these fibers were positive with both the von Kossa and Verhoeff-van Gieson stains.

LIMITATIONS

The cases in the series were not compared with age-, sex-, and location-matched biopsy specimens or biopsy specimens of other fibrosing conditions.

CONCLUSION

This constellation of histologic changes is diagnostic of lipodermatosclerosis. The presence of pseudoxanthoma elasticum-like changes is a helpful, but not unequivocal, clue in this condition.

Calcinosis in Rheumatic Diseases

BACKGROUND

Calcinosis, or dystrophic soft-tissue calcification, occurs in damaged or devitalized tissues in the presence of normal calcium/phosphorus metabolism. It is often noted in the subcutaneous tissues of connective tissues diseases--primarily systemic lupus erythematosus, scleroderma, or dermatomyositis--and may involve a relatively localized area or be widespread. The calcinotic accumulations may lead secondarily to muscle atrophy, joint contractures, and skin ulceration complicated by recurrent episodes of local inflammation and infection.

OBJECTIVES

To review the classification, pathogenesis, clinical features, and treatment of calcinosis in rheumatic diseases.

METHOD

A MEDLINE search of articles from 1972 to 2004 was conducted utilizing the index word "calcinosis" with the coindexing terms "scleroderma," "lupus," "dermatomyositis," and "dystrophic calcification."

RESULTS

Calcinosis may be the source of both pain and disability in connective tissue disease patients. Illustrative cases of patients with severe calcinosis are described. The literature available was critically reviewed. While warfarin, colchicine, probenecid, bisphosphonates, diltiazem, minocycline, aluminum hydroxide, salicylate, surgical extirpation, and carbon dioxide laser therapies have been used, no treatment has convincingly prevented or reduced calcinosis.

CONCLUSIONS

Calcinosis is common in the conditions reviewed and a number of agents have been used for treatment. However, the approach to calcinosis management is disorganized, beginning with the lack of a generally accepted classification and continuing with a lack of systematic study and clinical therapeutic trials.