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Noguchi T, Sakamoto A, Kakehi K, Matsuda S. New method of local adjuvant therapy with bicarbonate Ringer's solution for tumoral calcinosis: A case report. World J Orthop 2024; 15:302-309. [PMID: 38596192 PMCID: PMC10999962 DOI: 10.5312/wjo.v15.i3.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/06/2024] [Accepted: 01/24/2024] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Tumoral calcinosis is a condition characterized by deposits of calcium phosphate crystals in extra-articular soft tissues, occurring in hemodialysis patients. Calcium phosphate crystals are mainly composed of hydroxyapatite, which is highly infiltrative to tissues, thus making complete resection difficult. An adjuvant method to remove or resolve the residual crystals during the operation is necessary. CASE SUMMARY A bicarbonate Ringer's solution with bicarbonate ions (28 mEq/L) was used as the adjuvant. After resecting calcium phosphate deposits of tumoral calcinosis as much as possible, while filling with the solution, residual calcium phosphate deposits at the pseudocyst wall can be gently scraped by fingers or gauze in the operative field. A 49-year-old female undergoing hemodialysis for 15 years had swelling with calcium deposition for 2 years in the shoulders, bilateral hip joints, and the right foot. A shoulder lesion was resected, but the calcification remained and early re-deposition was observed. Considering the difficulty of a complete rection, we devised a bicarbonate dissolution method and excised the foot lesion. After resection of the calcified material, the residual calcified material was washed away with bicarbonate Ringer's solution. CONCLUSION The bicarbonate dissolution method is a new, simple, and effective treatment for tumoral calcinosis in hemodialysis patients.
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Affiliation(s)
- Takashi Noguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Akio Sakamoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kensaku Kakehi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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Ryan PM, Sprowls GR, Ward RA, Zriek R, Fritchie K. Tumoral calcinosis of the knee treated with open, physeal sparing iliotibial band ACL reconstruction. Knee 2023; 43:1-9. [PMID: 37201440 DOI: 10.1016/j.knee.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 05/20/2023]
Abstract
Tumoral calcinosis is a hereditary disease of calcium and phosphate metabolism causing peri-articular tumors of calcium deposits. We present a case of tumoral calcinosis in a 13-year-old male with a history of a 12q13.11 genetic deletion. Surgical resection of the tumor necessitated resection of the ACL in its entirety with curettage and adjuvant therapy to the lateral femoral notch, which resulted in ligamentous instability and bony structural incompetency at the femoral insertion. Given the patient's radiographically-apparent skeletal immaturity, and lack of reliable bony architecture to accommodate a femoral ACL tunnel, ACL reconstruction was performed using a physeal-sparing technique. This is a case of tumoral calcinosis treated with, to our knowledge, the first ACL reconstruction using this modified open technique.
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Affiliation(s)
- Patrick M Ryan
- Department of Orthopaedic Surgery, Baylor Scott & White Health, Temple, TX, United States.
| | - Gregory R Sprowls
- Department of Orthopaedic Surgery, Baylor Scott & White Health, Temple, TX, United States
| | - Russell A Ward
- Department of Orthopaedic Surgery, Baylor Scott & White Health, Temple, TX, United States; College of Medicine, Texas A&M University, Temple, TX, United States
| | - Riyam Zriek
- College of Medicine, Texas A&M University, Temple, TX, United States
| | - Karen Fritchie
- College of Medicine, Texas A&M University, Temple, TX, United States
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Perumal NL, Padidela R. Phosphate Homeostasis and Disorders of Phosphate metabolism. Curr Pediatr Rev 2022; 19:CPR-EPUB-128362. [PMID: 36545737 DOI: 10.2174/1573396319666221221121350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
Phosphate is indispensable for human life and evolutionary changes over several millions of years have established tightly regulated mechanisms to ensure phosphate homeostasis. In this process, calcium and phosphate metabolism have come to be intricately linked together. Three hormones (PTH, FGF23 and Calcitriol) maintain the fine balance of calcium and phosphate metabolism through their actions at three sites (the gut, the kidneys and the skeleton). Disorders that disrupt this balance can have serious clinical consequences. Acute changes in serum phosphate levels can result in life threatening complications like respiratory failure and cardiac arrythmias. Chronic hypophosphataemia predominantly affects the musculoskeletal system and presents as impaired linear growth, rickets, osteomalacia and dental problems. Hyperphosphataemia is very common in the setting of chronic kidney disease and can be difficult to manage. A thorough understanding of calcium and phosphate homeostasis is essential to diagnose and treat conditions associated with hypo and hyperphosphataemia. In this review, we will discuss the calcium and phosphate metabolism, aetiologies and management of hypo and hyperphosphataemia.
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Affiliation(s)
| | - Raja Padidela
- Department of Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Anderson KD, Malek F, Szewc RG, McCarthy WA, Hartzler RU. Tumoral calcinosis complicating a reverse total shoulder arthroplasty: a case report. JSES Rev Rep Tech 2022; 2:87-91. [PMID: 37588291 PMCID: PMC10426530 DOI: 10.1016/j.xrrt.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
| | - Farbod Malek
- Bone and Joint Surgery Associates, San Antonio, TX, USA
| | - Robert G. Szewc
- Kidney Hypertension & Transplant Specialists, San Antonio, TX, USA
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Huang J, Cao LG, Zhang TR, Li SM, Meng QQ. Primary hyperphosphatemic tumoral calcinosis: a case report. Osteoporos Int 2022; 33:309-312. [PMID: 34245344 DOI: 10.1007/s00198-021-06056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
Tumoral calcinosis (TC) is a rare disease characterized by periarticular soft tissue calcification. Some cases were reported in Africa and the Middle East. We report an 11-year-old Chinese girl presenting with recurrent multiple subcutaneous masses around the right elbow and hip regions. Although we found abnormalities in FGF23, a protein associated with phosphate metabolism, no positive results were observed in gene sequencing and analysis. The imaging features, laboratory examination, and pathology results confirmed our diagnosis. By using oral phosphorus-lowering drugs (acetazolamide) combined with complete surgical excision, good results were achieved, and no recurrence was reported during the follow-up of 18 months. We report a case of primary hyperphosphatemic TC. The combined use of oral phosphorus-lowering drugs (acetazolamide) and complete surgical excision produced good results, and no recurrence was reported during the follow-up of 18 months.
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Affiliation(s)
- J Huang
- Department of Orthopedics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - L-G Cao
- Department of Orthopedics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - T-R Zhang
- Department of Orthopedics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - S-M Li
- Department of Orthopedics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China.
| | - Q-Q Meng
- Department of Orthopedics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China.
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Jin Q, Zhou H, Lu H. Intramuscular tumoral calcinosis near the arteriovenous fistula mimicking acute infection. Sci Prog 2021; 104:368504211018560. [PMID: 34157884 PMCID: PMC10455013 DOI: 10.1177/00368504211018560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tumoral calcinosis is a kind of tumorous calcified masses, which may progress in patients with chronic renal failure. Uremic tumoral calcinosis in the brachioradialis muscle presented like acute infection of the arteriovenous fistula has not been previously reported. A 49-year-old man came to our hospital with a 9-year history of hemodialysis and secondary hyperparathyroidism. He had a huge painful mass in the left forearm at admission. The treatment was debridement and cytoreductive surgery accompanied by parathyroidectomy and medical management of calcium phosphate imbalance. After the comprehensive treatment, the patient recovered from his previously affected forearm. This is an enlightening case of intramuscular tumoral calcinosis mass that presented mimicking the infection of the arteriovenous fistula. Nephrologists and surgeons should pay attention to early diagnosis and proper management of the primary disease to master the indication and opportunity of resection.
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Affiliation(s)
- Qianjun Jin
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P.R. China
| | - Haiying Zhou
- College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P.R. China
| | - Hui Lu
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P.R. China
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Abstract
Congenital diseases that could result in hyperphosphatemia at an early age include hyperphosphatemic familial tumoral calcinosis (HFTC)/hyperostosis-hyperphosphatemia syndrome (HHS) and congenital hypoparathyroidism/pseudohypoparathyroidism due to the insufficient activity of fibroblast growth factor (FGF) 23 and parathyroid hormone. HFTC/HHS is a rare autosomal recessive disease caused by inactivating mutations in the FGF23, UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase 3 (GALNT3), or Klotho (KL) genes, resulting in the excessive cleavage of active intact FGF23 (FGF23, GALNT3) or increased resistance to the action of FGF23 (KL). Massive ectopic calcification, known as tumoral calcinosis (TC), is seen in periarticular soft tissues, typically in the hip, elbow, and shoulder in HFTC/HHS, reducing the range of motion. However, other regions, such as the eye, intestine, vasculature, and testis, are also targets of ectopic calcification. The other symptoms of HFTC/HHS are painful hyperostosis of the lower legs, dental abnormalities, and systemic inflammation. Low phosphate diets, phosphate binders, and phosphaturic reagents such as acetazolamide are the treatment options for HFTC/HHS and have various consequences, which warrant the development of novel therapeutics involving recombinant FGF23.
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Affiliation(s)
- Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
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Abstract
FGF23 is a phosphotropic hormone produced by the bone. FGF23 works by binding to the FGF receptor-Klotho complex. Klotho is expressed in several limited tissues including the kidney and parathyroid glands. This tissue-restricted expression of Klotho is believed to determine the target organs of FGF23. FGF23 reduces serum phosphate by suppressing the expression of type 2a and 2c sodium-phosphate cotransporters in renal proximal tubules. FGF23 also decreases 1,25-dihydroxyvitamin D levels by regulating the expression of vitamin D-metabolizing enzymes, which results in reduced intestinal phosphate absorption. Excessive actions of FGF23 cause several types of hypophosphatemic rickets/osteomalacia characterized by impaired mineralization of bone matrix. In contrast, deficient actions of FGF23 result in hyperphosphatemic tumoral calcinosis with high 1,25-dihydroxyvitamin D levels. These results indicate that FGF23 is a physiological regulator of phosphate and vitamin D metabolism and indispensable for the maintenance of serum phosphate levels.
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Azami A, Mohebbipour Loron A, Anari H, Matin S. Case report: a report of a rare case tumoral calcinosis syndrome in a patient afflicted with psoriatic arthritis. Arch Osteoporos 2020; 15:106. [PMID: 32700242 DOI: 10.1007/s11657-020-00779-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/26/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED In this report, we describe the case in which tumoral calcinosis occurs in a patient afflicted with psoriatic arthritis. INTRODUCTION Tumoral calcinosis is a benign disease which occurs quite rarely. It is similar to a neoplasm and appears as the result of calcium deposition in the soft tissues around large joints. This disease can develop as a primary or secondary disease in patients. CASE REPORT In this report, the authors describe the case in which tumoral calcinosis occurs in a female afflicted with psoriatic arthritis. We review the patient's clinical and para clinical findings. CONCLUSIONS Our report is the first one in which an Iranian patient with psoriatic arthritis has been diagnosed to have tumoral calcinosis. Imaging and pathological examinations are the common diagnostic methods. The main treatment for that is tumor resection.
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Affiliation(s)
- Ahad Azami
- Rheumatology Division, Department of Internal Medicine, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | | | - Hasan Anari
- Department of Radiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Somaieh Matin
- Department of Internal Medicine, School of Medicine, Ardabil University of Medical Sciences, Daneshghah Street, Ardabil, Iran.
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Zuo QY, Cao X, Liu BY, Yan D, Xin Z, Niu XH, Li C, Deng W, Dong ZY, Yang JK. Clinical and genetic analysis of idiopathic normophosphatemic tumoral calcinosis in 19 patients. J Endocrinol Invest 2020; 43:173-183. [PMID: 31535357 DOI: 10.1007/s40618-019-01097-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 08/02/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE Tumoral calcinosis is a rare clinicopathological entity characterized by ectopic soft-tissue calcification, typically periarticular. Normophosphatemic tumoral calcinosis is seldom reported in East Asian populations, and the preoperative diagnosis is often elusive. This study was performed to characterize the clinical profile of normophosphatemic tumoral calcinosis and investigate the presence of the SAMD9 gene mutation. METHODS The clinical features, pathological examination findings, and outcomes of 19 subjects were retrospectively reviewed. All patients were analyzed for SAMD9 gene mutation using paraffin-embedded tumoral calcinosis specimens. RESULTS Nineteen subjects were analyzed (7 males, 12 females). Their mean age at surgery, mean age at symptom onset, and median disease duration was 51.9 ± 17.3 (range 7-75) years, 49.1 ± 17.2 (range 7-74) years, and 1.3 (interquartile range 0.5-3.0) years, respectively. Lesions were located in the hand in 8 (42.1%) subjects; wrist in 5 (26.3%); shoulder in 2 (10.5%); and hip, knee, buttock, and scrotum in 1 (5.3%) subject each. The lesions in 17 (89.5%) subjects were located around the joints [small joints (hand and wrist) in 13 (68.4%) and large joints (shoulder, hip, and knee) in 4 (21.1%)]. Lesions occurred in the upper limbs in 15 (78.9%) subjects and in the lower limbs in 2 (10.5%). Multiple-lesion involvement (distal right index finger and middle finger) occurred in one (5.3%) subject. Symptoms included pain in 15 (78.9%) subjects, impaired mobility in 5 (26.3%), swelling in 5 (26.3%), numbness in 2 (10.5%), and an asymptomatic mass in 2 (10.5%). The serum inorganic phosphorus concentration was normal in all 19 subjects (mean 1.17 ± 0.15 mmol/L). The serum calcium concentration was normal in 18 subjects and low in 1. The serum alkaline phosphatase concentration was normal in all 19 subjects. Pathological examination indicated multiple nodules of calcified materials that manifested an amorphous or granular blue-purple crystal and were surrounded by proliferation of mononuclear or multinuclear macrophages, osteoclastic-like giant cells, fibroblasts, and chronic inflammatory cells. Notably, different phases of pathological manifestations were observed in the same microscopic field. During follow-up (0.5-65.0 months), no recurrence of tumoral calcinosis was observed in 18 (94.7%) subjects, but 1 subject developed in situ recurrence of an asymptomatic subcutaneous mass after 6 months postoperatively. Genetic analysis in all 19 subjects revealed no SAMD9 gene mutations. CONCLUSIONS Most subjects were females and developed calcinosis in adulthood. Small joints (hand and wrist) and the upper limbs were frequently involved. The presence of different phases of pathological features in the same subject suggests that about half of the study participants had been misdiagnosed with another condition (such as gout, osteoarthritis, etc.). Complete surgical excision led to cure without recurrence during follow-up in majority of the study participants.
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Affiliation(s)
- Q-Y Zuo
- Beijing Diabetes Institute, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - X Cao
- Beijing Diabetes Institute, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - B-Y Liu
- Department of Pathology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - D Yan
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Z Xin
- Beijing Diabetes Institute, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - X-H Niu
- Department of Orthopaedic Oncology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - C Li
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - W Deng
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Z-Y Dong
- Department of Nephrology, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center of Kidney Diseases, Chinese PLA General Hospital, Beijing, 100039, China
| | - J-K Yang
- Beijing Diabetes Institute, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
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Westermann L, Isbell LK, Breitenfeldt MK, Arnold F, Röthele E, Schneider J, Widmeier E. Recuperation of severe tumoral calcinosis in a dialysis patient: A case report. World J Clin Cases 2019; 7:4004-4010. [PMID: 31832402 PMCID: PMC6906553 DOI: 10.12998/wjcc.v7.i23.4004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/06/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND One of the common late sequela in patients with end-stage renal disease (ESRD) is the calcium phosphate disorder leading to chronic hypercalcemia and hyperphosphatemia causing the precipitation of calcium salt in soft tissues. Tumoral calcinosis is an extremely rare clinical manifestation of cyst-like soft tissue deposits in different periarticular regions in patients with ESRD and is characterized by extensive calcium salt containing space-consuming painful lesions. The treatment of ESRD patients with tumoral calcinosis manifestation involves an increase in or switching of renal replacement therapy regimes and the adjustment of oral medication with the goal of improved hypercalcemia and hyperphosphatemia.
CASE SUMMARY We describe a 40-year-old woman with ESRD secondary to IgA-nephritis and severe bilateral manifestation of tumoral calcinosis associated with hypercalcemia, hyperphosphatemia and tertiary hyperparathyroidism. The patient was on continuous ambulatory peritoneal dialysis and treatment with vitamin D analogues. After switching her to a daily hemodialysis schedule and adjusting the medical treatment, the patient experienced a significant dissolution of her soft tissue calcifications within a couple of weeks. Complete remission was achieved 11 mo after the initial diagnosis.
CONCLUSION Reduced patient compliance and subsequent insufficiency of dialysis regime quality contribute to the aggravation of calcium phosphate disorder in a patient with ESRD leading to the manifestation of tumoral calcinosis. However, the improvement of the treatment strategy and reinforcement of patient compliance enabled complete remission of this rare disease entity.
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Affiliation(s)
- Lukas Westermann
- Department of Medicine IV, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | - Lisa K Isbell
- Department of Medicine I, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | | | - Frederic Arnold
- Department of Medicine IV, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | - Elvira Röthele
- Department of Medicine IV, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | - Johanna Schneider
- Department of Medicine IV, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | - Eugen Widmeier
- Department of Medicine IV, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
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Zhang Y, Zhang Y, Zhang VW, Zhang C, Ding H, Yin A. Mutations in both SAMD9 and SLC19A2 genes caused complex phenotypes characterized by recurrent infection, dysphagia and profound deafness - a case report for dual diagnosis. BMC Pediatr 2019; 19:364. [PMID: 31638924 PMCID: PMC6802302 DOI: 10.1186/s12887-019-1733-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 09/20/2019] [Indexed: 12/31/2022] Open
Abstract
Background Phenotypic difference is general in Mendelian disease. Due to the extremely low incidence for a single disease, phenotype spectrum needs to be expanded. Meanwhile, earlier knowledge says patients who suffered from two kinds of different Mendelian disease are very rare. Case presentation We describe a case of neonatal male with genital anomalies, growth delay, skin hyperpigmentation, chronic lung disease with recurrent infection, anemia, and severe deafness. Without any clear etiology after routine workflow, whole exome sequencing was carried on. A pathogenic de novo SAMD9 mutation and compound heterozygous likely-pathogenic variants in SLC19A2 were identified. Some symptoms were improved after the patient was treated with vitamin B1. Unfortunately, the boy died from sepsis and multiple organ failure before 1 year old. Conclusion Combining the phenotype and clinical progress of treatment, we report that it is the first case of a patient with both MIRAGE syndrome and TRMA syndrome.
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Affiliation(s)
- Yan Zhang
- Center for Medical Genetics, Guangdong Women and Children Hospital, 521 Xingnandadao, Guangzhou, 511442, China
| | - Yi Zhang
- Euler Genomics Co. Ltd., Beijing, China
| | - Victor Wei Zhang
- AmCare Genomics Laboratory, Guangzhou, China.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Chunyi Zhang
- Neonatology Department, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hongke Ding
- Center for Medical Genetics, Guangdong Women and Children Hospital, 521 Xingnandadao, Guangzhou, 511442, China
| | - Aihua Yin
- Center for Medical Genetics, Guangdong Women and Children Hospital, 521 Xingnandadao, Guangzhou, 511442, China.
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Wang J, Zeng M, Yang G, Huang Y, Wu B, Guo J, Wang N, Xing C. Effects of parathyroidectomy on tumoral calcinosis in uremic patients with secondary hyperparathyroidism. BMC Surg 2019; 19:133. [PMID: 31510980 PMCID: PMC6740033 DOI: 10.1186/s12893-019-0603-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 09/04/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Tumoral calcinosis (TC) is a rare disease derived from uremic secondary hyperparathyroidism (SHPT). However, parathyroidectomy (PTX) seems to be ineffective at relieving TC in some patients. In this study, we investigated the relationship between PTX and TC shrinkage. METHODS We retrospectively followed up nine TC patients who underwent PTX, dividing them into two groups: those with TC size reduced by > 80% were in the "effective group" (group A), and the rest in the "ineffective group" (group B). RESULTS We enrolled nine patients (7 men; mean age 38.6 ± 10.9 years) with SHPT-related TC. One patient with calciphylaxis was excluded due to sudden death. The efficiency of PTX in causing TC regression was 62.5% (5 patients in group A). Group A had a shorter overall duration of TC (6 [5.5, 6.0] vs. 9 [8.0, 10.0] months; P = 0.02) and higher serum levels of alkaline phosphatase (ALP; 408.0 [217.9, 1101.7] vs. 90.8 [71.0, 102.1] pg/ml; P = 0.03) and high-sensitivity C-reactive protein (hs-CRP; 82.7 [55.0, 112.4] vs. 3.1 [3.1, 4.5] mg/l; P = 0.02). Average calcium supplementation within 1 week of surgery was significantly greater in group A than in group B (96.8 [64.1, 105.3] vs. 20.1 [13.1, 32.7] g; P = 0.04). Patients in both the groups demonstrated similar serum phosphate levels before PTX, but these levels were higher in group B than in group A at follow-up times (3 months, P = 0.03; 6 months, P = 0.03). CONCLUSIONS The shorter duration of pre-existing TC and higher ALP levels before PTX, as well as lower serum phosphate levels after PTX, were correlated with effective SHPT-TC shrinkage.
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Affiliation(s)
- Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Yaoyu Huang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Buyun Wu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Jing Guo
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China.
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China.
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Sha Y, Hong K, Liew MKM, Lum JL, Wong RCW. Juxta-articular tumoral calcinosis associated with the temporomandibular joint: a case report and concise review. BMC Oral Health 2019; 19:138. [PMID: 31288794 PMCID: PMC6617841 DOI: 10.1186/s12903-019-0816-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/05/2019] [Indexed: 12/13/2022] Open
Abstract
Background Tumoral calcinosis is an uncommon clinicopathological condition which is characterized by the formation of calcium salt deposition in intra-articular or peri-articular soft tissues. It usually presents as a focal growth of hard tissue, either solitary or multiple, beneath the skin and connective tissue. Diagnostic techniques mainly include clinical and radiographic evaluation. The most commonly involved locations include the hip, elbow, shoulder and knee. Involvement of the head and neck regions are far less common. There have been 5 case reports of temporomandibular joint involvement in the literature so far. Case presentation We present a case report which describes the diagnosis and management of a 59 year old female patient with chronic right temporomandibular joint pain and localized bony hard swelling over the right pre-auricular region. Patient retained normal range of motion and mouth opening. Computed tomography taken showed a radio-opaque juxta-articular ovoid mass over the right pre-auricular region in close proximity but not fused to the mandibular condyle. Surgical excision was performed for this swelling via a pre-auricular approach under general anaesthesia. Histological examination performed confirmed the diagnosis of tumoral calcinosis. Pain at the right temporomandibular joint was resolved after the surgery. Serum calcium and phosphate levels were normal in this patient. Conclusion Surgical excision is the primary treatment modality for tumoral calcinosis. Tumoral calcinosis may be associated with elevated serum calcium and phosphate levels. In patients with elevated serum electrolytes, it is important to consider the overall systemic health in management of this condition. Management of serum electrolytes levels plays a role in reducing recurrence rates. This case report and review aims to discuss the diagnosis, treatment and overall systemic management of this rare condition.
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Affiliation(s)
- Yang Sha
- Discipline of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| | - Kanglun Hong
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore
| | - Melvin Kang Ming Liew
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore
| | - Jing Li Lum
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore
| | - Raymond Chung Wen Wong
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore. .,Discipline of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore.
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Abstract
BACKGROUND Tumoral calcinosis has been defined as a pathological condition which presents as calcified masses around juxta-articular structures. The etiology of this pathology is still not well understood but degenerative spine diseases seem to play a role. The diagnosis of tumoral calcinosis preoperatively can prevent intraoperative confusion from unexpected findings, especially in cases where removal of the calcified mass is essential to treating the patient's symptoms, i.e. nerve compression causing radiculopathy. CASE DESCRIPTION We present two cases of patients who presented with spinal radiculopathy and mechanical pain. Both patients were found to have a calcified facet joint mass and underwent surgical resection of the mass combined with spinal fusion resulting in excellent symptom relief post-surgery. CONCLUSION For accurate diagnosis and management of tumoral calcinosis, a high index of suspicion together with neuro imaging remains a good place to start. Intra-operative visualization of the pathology as well as permanent pathology reports is a good adjunct to confirming the diagnosis.
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Affiliation(s)
- James Ebot
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA.
| | - Eric Nottmeier
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
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Abstract
Tumoral calcinosis is a condition characterized by deposition of calcium salts in the skin and sub- cutaneous tissue, commonly found around the joints. However, tumoral calcinosis of the auricle is extremely rare. We present the case of a 13-year-old boy with tumoral calcinosis of the helix of the ear auricle. A 13-year-old boy presented with a 10-year history of an enlarging mass on the left auricle. The mass was hard, non-tender, and non-compressible. The patient had no history of trauma. Complete surgical excision and pathological examination of the specimen was performed. The final diagnosis of the excised mass was tumoral calcinosis. After 9 months of follow-up, there were no signs of recurrence of the tumor and the patient was satisfied with the surgical results. Tumoral calcinosis of the auricle is extremely rare and may be misdiagnosed as other tumors. Pathological examination is essential for definitive diagnosis and complete surgical excision should be considered as the treatment of choice.
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Affiliation(s)
- Sam Yong Lee
- Department of Plastic and Reconstructive Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Han Gyeol Lee
- Department of Plastic and Reconstructive Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Kwang Seog Kim
- Department of Plastic and Reconstructive Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Ha Hwang
- Department of Plastic and Reconstructive Surgery, Chonnam National University Medical School, Gwangju, Korea
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17
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Guo R, Kurata T, Kondo T, Imanishi T, Mizuno T, Sakakibara T, Kasai Y. Tumoral calcinosis in the cervical spine: a case report and review of the literature. J Med Case Rep 2017; 11:304. [PMID: 29073937 PMCID: PMC5658931 DOI: 10.1186/s13256-017-1474-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/21/2017] [Indexed: 12/03/2022] Open
Abstract
Background Tumoral calcinosis is rarely located in spine. A 55-year-old Japanese woman with cervical tumoral calcinosis is presented, along with a review of the literature relating to tumoral calcinosis in the spine. We discussed the etiology, diagnosis, and management of this condition. Case presentation We report a case of a patient with cervical tumoral calcinosis with end-stage renal disease. A computed tomography scan showed a lobulated, calcified mass around the right facet joint at the fourth-fifth cervical spine and calcifications were also observed in the right intervertebral foramens at fourth-fifth cervical spine and fifth-sixth cervical spine levels and the anterior wall of the spinal canal. By performing a cervical decompression and stabilization, the patient recovered from her neurological symptoms. Conclusions Although tumoral calcinosis is rarely located in the spine, it should be considered in the differential diagnosis of spinal lesions. If a calcified mass causes acute neurological symptoms, resection of the mass is still the most important treatment.
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Affiliation(s)
- Rui Guo
- Department of Spinal Surgery and Medical Engineering, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.,Department of Orthopaedics, The Third People's Hospital of Kunshan, Kunshan, Jiangsu, China
| | - Tatsuya Kurata
- Department of Orthopaedic Surgery, Sakakibara Onsen Hospital, Tsu City, Mie, Japan
| | - Tetsushi Kondo
- Department of Orthopaedic Surgery, Murase Hospital, Suzuka City, Mie, Japan
| | - Takao Imanishi
- Department of Orthopaedic Surgery, Murase Hospital, Suzuka City, Mie, Japan
| | - Tetsutaro Mizuno
- Department of Spinal Surgery and Medical Engineering, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Toshihiko Sakakibara
- Department of Spinal Surgery and Medical Engineering, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Yuichi Kasai
- Department of Spinal Surgery and Medical Engineering, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
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18
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Ibrahim Montasser D, Issouani J, Hassani M, Kabbaj D. Tumoral calcinosis: Diffuse multifocal form in hemodialysis patients. Two case reports. Orthop Traumatol Surg Res 2017; 103:815-820. [PMID: 28576700 DOI: 10.1016/j.otsr.2017.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 12/07/2016] [Accepted: 01/17/2017] [Indexed: 02/02/2023]
Abstract
Orthopedic surgeons are often consulted for diagnosis of MASS syndrome, imaging showing periarticular calcification, or joint stiffness. Such presentations in a dialyzed patient should suggest tumoral calcinosis, which is a rare complication of dialysis, often diagnosed wrongly or late. It is often associated with calcium phosphate balance disorder, in which treatment is difficult and must take account of known contributing factors: severe hyperparathyroidism, increased phosphocalcic product, therapeutic calcium and vitamin D overload, and bone turnover slowed for varying reasons. We report a clinical, radiological and therapeutic description of two cases of tumoral calcinosis, which consists in deposits of hydroxyapatite, the crystalline form of calcium phosphate, in diffuse multifocal periarticular locations, inducing both esthetic and functional damage.
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Affiliation(s)
- D Ibrahim Montasser
- Service de néphrologie, dialyse et transplantation rénale, hôpital militaire Mohammed V, Rabat, Morocco.
| | - J Issouani
- Service d'endocrinologie, hôpital militaire Mohammed V, Rabat, Morocco
| | - M Hassani
- Service de néphrologie, hôpital Moulay Ismail, Meknes, Morocco
| | - D Kabbaj
- Service de néphrologie, dialyse et transplantation rénale, hôpital militaire Mohammed V, Rabat, Morocco
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19
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Clinkenbeard EL, White KE. Heritable and acquired disorders of phosphate metabolism: Etiologies involving FGF23 and current therapeutics. Bone 2017; 102:31-39. [PMID: 28159712 PMCID: PMC5537045 DOI: 10.1016/j.bone.2017.01.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 01/20/2017] [Accepted: 01/29/2017] [Indexed: 10/20/2022]
Abstract
Phosphate is critical for many cellular processes and structural functions, including as a key molecule for nucleic acid synthesis and energy metabolism, as well as hydroxyapatite formation in bone. Therefore it is critical to maintain tight regulation of systemic phosphate levels. Based upon its broad biological importance, disruption of normal phosphate homeostasis has detrimental effects on skeletal integrity and overall health. Investigating heritable diseases of altered phosphate metabolism has led to key discoveries underlying the regulation and systemic actions of the phosphaturic hormone Fibroblast growth factor-23 (FGF23). Both molecular and clinical studies have revealed novel targets for the development and optimization of therapies for disorders of phosphate handling. This review will focus upon the bridge between genetic discoveries involving disorders of altered FGF23 bioactivity, as well as describe how these findings have translated into pharmacologic application.
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Affiliation(s)
- Erica L Clinkenbeard
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth E White
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA.
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Affiliation(s)
- Michael J Econs
- Indiana University School of Medicine, 1120 W. Michigan Street, Gatch Clinical Building 459, Indianapolis, Indiana 46202-5111, United States.
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21
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Zapałowicz K, Stasiów B, Ciupińska-Kajor M, Piwowarski W. Tumoral calcinosis of the cervical spine in a dialysis patient. Case report and review of the literature. Neurol Neurochir Pol 2016; 51:163-169. [PMID: 28012693 DOI: 10.1016/j.pjnns.2016.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/06/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
Abstract
The authors present a case of tumoral calcinosis (TC) in a patient with chronic renal insufficiency. The clinical course, imaging features and microscopic findings are detailed. A 60-year-old woman with a 4-year history of hemodialysis presented with a painful mass in the right posterior cervical triangle. The neuroimaging revealed polycystic mass bulging from the C3-C5 facet joints and lamina on the right. The majority of cystic mass was excised and microscopic features of the specimen were consistent with TC. Tumoral calcinosis is a rare disease characterized by calcium salt deposits in periarticular soft tissue, which enlarge to form tumor-like cystic masses containing chalky calcareous material. TC is typically seen around large joints but rarely in the spine. Review of past publications provided six cases of TC involving the spine in dialyzed patients.
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Affiliation(s)
- Krzysztof Zapałowicz
- Department of Neurosurgery, Independent Public Clinical Hospital No. 7 of the Medical University of Silesia in Katowice, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland.
| | - Bartłomiej Stasiów
- The Unit of Diagnostic Imaging, Independent Public Clinical Hospital No. 7 of the Medical University of Silesia in Katowice, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
| | - Monika Ciupińska-Kajor
- Department of Pathomorphology, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Wojciech Piwowarski
- Department of Neurosurgery, Independent Public Clinical Hospital No. 7 of the Medical University of Silesia in Katowice, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
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22
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Mageau A, Guigonis V, Ratzimbasafy V, Bardin T, Richette P, Urena P, Ea HK. Intravenous sodium thiosulfate for treating tumoral calcinosis associated with systemic disorders: Report of four cases. Joint Bone Spine 2016; 84:341-344. [PMID: 27955821 DOI: 10.1016/j.jbspin.2016.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/26/2016] [Indexed: 01/01/2023]
Abstract
Intravenous sodium thiosulfate (ivSTS) is a promising new therapeutic option for calciphylaxis related to end-stage renal disease. However, its effect on tumoral calcinosis (TC) complicating autoimmune connective-tissue diseases has been scarcely described. We report here 4 cases (3 adults and 1 child) of TC treated with ivSTS. TC was secondary to CREST syndrome, dermatomyositis (1 adult and 1 child) and systemic erythematous lupus and involved multiple sites in all cases. In all 4 patients, TC was responsible for joint pain, reduced mobility, inflammatory flares and skin fistulations. One patient experienced difficulty sitting due to the pain induced by calcified lesions on the buttock; another patient had major disability, moved only with wheelchair and was under opioid treatment for pain. For all patients, treatment with several medications before STS was unsuccessful. The 3 adults received at least 6 cycles of ivSTS (20g/d, 5 days/month) and the child received a daily infusion of 17g STS during 1 month then a 9-g/d infusion during 3 months. Two adults and the child showed clinical improvement with STS treatment and the third adult felt disappointed and stopped STS treatment after 6 months. The child also stopped STS after 6 months due to vomiting. In one patient, an intensive regimen of ivSTS (20g every 2 days) controlled recurrent flares and fistulations. Unfortunately, TC remained unchanged. Further studies are needed to decipher how STS modulates ectopic calcification, the optimal regimen and posology.
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Affiliation(s)
- Arthur Mageau
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Vincent Guigonis
- Service de pédiatrie, hôpital de la Mère et de l'Enfant, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Voa Ratzimbasafy
- Service de pharmacie, hôpital de la Mère et de l'Enfant, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Thomas Bardin
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France
| | - Pascal Richette
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France
| | - Pablo Urena
- Service de néphrologie et dialyse, Ramsay-Générale de Santé, clinique du Landy, 23, rue de Landy, 93400 Saint-Ouen, France
| | - Hang-Korng Ea
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France.
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23
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Kamar FB, Mann B, Kline G. Sudden onset of parathyroid hormone-independent severe hypercalcemia from reversal of tumoral calcinosis in a dialysis patient. BMC Nephrol 2016; 17:137. [PMID: 27683096 PMCID: PMC5041286 DOI: 10.1186/s12882-016-0355-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 09/21/2016] [Indexed: 12/16/2022] Open
Abstract
Background Tumoral calcinosis is a rare manifestation of extraskeletal calcification, featuring large calcified cystic masses in the periarticular regions of large joints. In chronic kidney disease (CKD), this disorder is thought to evolve through a chronically elevated calcium-phosphorus solubility product leading to calcium precipitation in soft tissue. Treating tumoral calcinosis in these patients involves interventions to lower the calcium-phosphorus product such as reduction in vitamin D therapy and intensive hemodialysis regimens. Case Presentation We report the case of a 54-year old woman with polycystic kidney disease on peritoneal dialysis with widespread tumoral calcinosis in the context of hypercalcemic tertiary hyperparathyroidism who had been on long-term alfacalcidol therapy. After withdrawal of the vitamin D analogue and initiation of daily hemodialysis, there was rapid dissolution of her tumoral calcium deposits with the abrupt onset of parathyroid hormone (PTH)-independent transient hypercalcemia that resolved once the soft tissue deposits disappeared. Conclusions Resorption of soft tissue calcific deposits may result in transient parathyroid hormone (PTH)-independent hypercalcemia. In CKD patients, this hypercalcemia causes a decrease in the PTH level, distinguishing it from tertiary hyperparathyroidism, though PTH may not be totally suppressed, the way it is seen in PTH-independent hypercalcemia in non-CKD patients.
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Affiliation(s)
- Fareed B Kamar
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Bikaramjit Mann
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gregory Kline
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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24
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Affiliation(s)
- Manel Jellouli
- Service de Pédiatrie, Hôpital Charles Nicolle, Tunis, Tunisie
| | - Tahar Gargah
- Service de Pédiatrie, Hôpital Charles Nicolle, Tunis, Tunisie
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25
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Niemann KE, Kröpil F, Hoffmann MF, Coulibaly MO, Schildhauer TA. A 23-year-old patient with secondary tumoral calcinosis: Regression after subtotal parathyroidectomy: A case report. Int J Surg Case Rep 2016; 23:56-60. [PMID: 27088846 PMCID: PMC4855743 DOI: 10.1016/j.ijscr.2016.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/07/2016] [Indexed: 11/19/2022] Open
Abstract
Tumoral calcinosis needs to be diagnosed correctly. Subtotal parathyroidectomy leads to rapid regression. Potential mutilations may be avoid by early subtotal parathyroidectomy.
Introduction Tumoral calcinosis (TC) is a rare disorder defined by hyperphosphatemia and ectopic calcifications in various locations. The most common form of TC is associated with disorders such as renal insufficiency, hyperparathyroidism, or hypervitaminosis D. The primary (hereditary) TC is caused by inactivating mutations in either the fibroblast growth factor 23 (FGF23), the GalNAc transferase 3 (GALNT3) or the KLOTHO (KL) gene. Presentation of case We report here a case of secondary TC in end-stage renal disease. The patient was on regular hemodialysis and presented with severe painful soft-tissue calcifications around her left hip and shoulder that had been increasing over the last two years. Initially, she was treated with dietary phosphate restriction and phosphate binders. Because of high phosphate blood levels, which were not yet managed with dialysis and medical therapy, a subtotal parathyroidectomy (sP) was performed. This approach demonstrated significant response. Three months after surgery a rapid regression of the tumors was observed. Disscusion Regardless of the etiology, the two types of TC do not differ in their radiologic or histopathologic presentations but need to be diagnosed correctly to initiate targeted and effective treatment. Considering the primary TC, primary treatment is early and complete surgical excision. In case of secondary TC surgical excision of the tumoral masses should be avoid because of extensive complications. These patients benefit from sP. Conclusion After initial conservative therapy chronic kidney disease patients with TC might benefit from sP to avoid prolonged suffering and potential mutilations.
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Affiliation(s)
- Katharina E Niemann
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
| | - Feride Kröpil
- Department of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany.
| | - Martin F Hoffmann
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
| | - Marlon O Coulibaly
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
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26
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Sobhani Eraghi A, Athari B, Kheirkhah Rahimabad P. Tumoral calcinosis of the foot: An unusual differential diagnosis of calcaneal mass. Int J Surg Case Rep 2015; 10:219-22. [PMID: 25884613 PMCID: PMC4430204 DOI: 10.1016/j.ijscr.2015.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/20/2015] [Accepted: 04/03/2015] [Indexed: 11/17/2022] Open
Abstract
We describe an unusual case of primary tumoral calcinosis of the foot in a 76-year-old female. We discuss the pathophysiology, diagnosis and therapeutic interventions of tumoral calcinosis. Tumoral calcinosis should be considered in the differential diagnosis of any soft tissue calcification.
Introduction Tumoral calcinosis (TC) is a rare disorder characterized by the development of calcified masses within the periarticular soft tissues of large joints. It commonly involves the hip, shoulders, and elbows. TC rarely involves the feet. Case presentation In this report, we describe an unusual case of primary TC of the foot in a 76-year-old female and discuss the pathophysiology, diagnosis, and therapeutic interventions of the condition. Discussion Due to the wide range of conditions mimicking TC, its diagnosis could be challenging. Diagnosis of TC is mainly based on the radiographic findings, the patient’s biochemical profile, and the medical history plus differentiating the condition from its mimics. Conclusion TC should be considered in the differential diagnosis of any soft tissue calcification.
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Affiliation(s)
- Amir Sobhani Eraghi
- Department of Orthopedics, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Babak Athari
- Department of Orthopedics, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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27
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Reilly AM, Gray AK, Moe SM, Ichikawa S. Nicotinamide treatment in a murine model of familial tumoral calcinosis reduces serum Fgf23 and raises heart calcium. Bone 2014; 67:139-44. [PMID: 25007710 PMCID: PMC4157335 DOI: 10.1016/j.bone.2014.06.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 06/23/2014] [Accepted: 06/26/2014] [Indexed: 01/08/2023]
Abstract
Mutations in the GALNT3 gene result in familial tumoral calcinosis, characterized by persistent hyperphosphatemia and ectopic calcific masses in soft tissues. Since calcific masses often recur after surgical removal, a more permanent solution to the problem is required. Nicotinamide is reported to lower serum phosphate by decreasing sodium-dependent phosphate co-transporters in the gut and kidney. However, its effectiveness in tumoral calcinosis remains unknown. In this study, we investigated nicotinamide as a potential therapy for tumoral calcinosis, using a murine model of the disease-Galnt3 knockout mice. Initially, five different doses of nicotinamide were given to normal heterozygous mice intraperitoneally or orally. Treatment had no effect on serum phosphate levels, but serum levels of a phosphaturic hormone, fibroblast growth factor 23 (Fgf23), decreased in a dose-dependent manner. Subsequently, high-dose nicotinamide (40mM) was tested in Galnt3 knockout mice fed a high phosphate diet. The radiographic data pre- and post-treatment showed that nicotinamide did not reverse the calcification. However, the treatment retarded calcification growth after 4weeks, while in the untreated animals, calcifications increased in size. The therapy did not affect serum phosphate levels, but intact Fgf23 decreased in the treated mice. The treated mice also had increased calcium in the heart. In summary, nicotinamide did not alter serum phosphate levels, likely due to compensatory decrease in Fgf23 to counteract the phosphate lowering effect of nicotinamide. Although increased calcium accumulation in the heart is a concern, the therapy appears to slow down the progression of ectopic calcifications.
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Affiliation(s)
- Austin M Reilly
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Amie K Gray
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sharon M Moe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Roudebush Veteran Administration Medical Center, Indianapolis, IN 46202, USA
| | - Shoji Ichikawa
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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28
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Fathi I, Sakr M. Review of tumoral calcinosis: A rare clinico-pathological entity. World J Clin Cases 2014; 2:409-414. [PMID: 25232542 PMCID: PMC4163761 DOI: 10.12998/wjcc.v2.i9.409] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/08/2014] [Accepted: 06/27/2014] [Indexed: 02/05/2023] Open
Abstract
Tumoral calcinosis (TC) has long been a controversial clinico-pathological entity. Its pathogenesis and genetic background have been gradually unravelled since its first description in 1943. According to the presence or absence of an underlying calcifying disease process, TC has been divided into primary and secondary varieties. Two subtypes of the primary variety exist; a hyper-phosphatemic type with familial basis represented by mutations in GalNAc transferase 3 gene (GALNT3), KLOTHO or Fibroblast growth factor 23 (FGF23) genes, and a normo-phosphatemic type with growing evidence of underlying familial base represented by mutation in SAMD9 gene. The secondary variety is mainly associated with chronic renal failure and the resulting secondary or tertiary hyperparathyroidism. Diagnosis of TC relies on typical radiographic features (on plain radiographs and computed tomography) and the biochemical profile. Magnetic resonance imaging can be done in difficult cases, and scintigraphy reflects the disease activity. Treatment is mainly surgical for the primary variety; however, a stage-oriented conservative approach using phosphate binders, phosphate restricted diets and acetazolamide should be considered before the surgical approach is pursued due to the high rate of recurrences and complications after surgical intervention. Medical treatment is the mainstay for treatment of the secondary variety, with failure warranting subtotal or total parathyroidectomy. Surgical intervention in these patients should be kept as a last resort.
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Jeong JJ, Ji JH, Shafi M, Lee JK. Hallux valgus deformity of foot with tumoral calcinosis: an unusual presentation. Foot Ankle Surg 2014; 20:e15-8. [PMID: 24480509 DOI: 10.1016/j.fas.2013.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 09/18/2013] [Accepted: 10/15/2013] [Indexed: 02/04/2023]
Abstract
Tumoral calcinosis is an uncommon disorder and characterized by development of calcified masses within the soft tissues near the large joints such as the hip, elbow, and shoulder and rarely occurs in the foot. We report a case of tumoral calcinosis at the first meta-tarso-phalangeal (MTP) joint of foot with hallux valgus deformity associated with bunion which required resection. Surgical excision of the calcific mass alone, without surgery to the minimal hallux valgus, resulted in resolution of symptoms, without recurrence of the lesion. Subsequently, speculative etiology, differential diagnostic considerations as well as the therapeutic interventions for tumoral calcinosis are discussed taking into consideration the current literature. We conclude that tumoral calcinosis should be considered in the differential diagnosis of a painful mass that develops in the small joints of the foot.
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Affiliation(s)
- Jae-Jung Jeong
- Department of Orthopedics, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, South Korea
| | - Jong-Hun Ji
- Department of Orthopedics, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, South Korea
| | - Mohamed Shafi
- Department of Orthopedics, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, South Korea.
| | - Jun-Ku Lee
- Department of Orthopedics, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, South Korea
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Banshelkikar SN, Argekar H, Bhoir A. Idiopathic Tumoral Calcinosis with Unusual Presentation-Case Report with Review of Literature. J Orthop Case Rep 2014; 4:59-62. [PMID: 27298986 PMCID: PMC4719331 DOI: 10.13107/jocr.2250-0685.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Tumoral calcinosis is an uncommon disorder characterised by the deposition of calcium phosphate in periarticular tissues. The deposits are usually around large joints; but rarely can be found around small joints of hand and feet. CASE REPORT We present the case of 13 year old female with three years history of spontaneous, progressively increasing, painful swellings along right middle finger and right heel. She was otherwise well and had normal serum calcium but elevated phosphate levels. Plain radiography demonstrated a dense lobulated cluster of calcific nodules within soft tissues consistent with a diagnosis of tumoral calcinosis. This diagnosis was confirmed on the basis of histopathological examination following surgical excision. CONCLUSION As such tumoral calcinosis is a rare entity and with such unusual presentations like in our case, it may lead to diagnostic confusion. Tumoral calcinosis should be considered in the differential diagnosis of painful swellings developing in the vicinity of small joints of hand and feet.
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Affiliation(s)
- Santosh Nagnath Banshelkikar
- Department Of Orthopaedics, Lokmanya Tilak Municipal Medical College And General Hospital, Sion. Mumbai. India,Address of Correspondence Dr. Santosh N Banshelkikar, Flat No 101, Bldg No 40/1, Siddhivinayak Chs, Near Municipal School, Tilaknagar - West. Mumbai - 400089. Mobile: +91 9930 40 21 22,
| | - Harshad Argekar
- Department Of Orthopaedics, Lokmanya Tilak Municipal Medical College And General Hospital, Sion. Mumbai. India
| | - Asit Bhoir
- Department Of Orthopaedics, Lokmanya Tilak Municipal Medical College And General Hospital, Sion. Mumbai. India
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Shpilberg KA, Blowe SE, Som PM. Mass-like and extensive secondary tumoral calcinosis in the neck and body of a patient on peritoneal dialysis. Clin Imaging 2013; 37:972-5. [PMID: 23751266 DOI: 10.1016/j.clinimag.2013.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/21/2012] [Accepted: 01/17/2013] [Indexed: 11/25/2022]
Abstract
We present a case of extensive tumoral calcinosis in a 42-year-old female with end-stage renal disease and secondary hyperparathyroidism on peritoneal dialysis. Periarticular calcified masses demonstrating fluid-calcium levels on computed tomography and containing chalky amorphous calcified material in the absence of neoplastic cells are the salient features of tumoral calcinosis. Although renal failure is the most common cause of secondary tumoral calcinosis, there are few reported cases of this condition occurring in patients on peritoneal dialysis. This case is also unusual due to the widespread and bulky nature of the disease with involvement of the neck and its quick onset and progression.
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Affiliation(s)
- A Alam
- Associate Professor (Radiodiagnosis & Imaging), Armed Forces Medical College, Pune-411 040
| | - M N Sree Ram
- Resident (Radiodiagnosis & Imaging), Armed Forces Medical College, Pune-411 040
| | - K Manrai
- Senior Advisor (Radiodiagnosis), 151 Base Hospital, C/o 99 APO
| | - R Bhardwaj
- Associate Professor (Pathology), Armed Forces Medical College, Pune-411 040
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