Perforating Calcinosis Cutis as a Complication of Intraosseous Fluid Infusion in the Setting of a Near-Drowning Event

Iatrogenic calcinosis cutis represents a subset of calcinosis cutis resulting secondary to treatments or procedures. We present the first report of calcinosis cutis resulting from the intraosseous infusion and one of a few cases with associated transepidermal elimination. A previously healthy 2-year-old female presented with a new-onset unilateral shin rash 1 week following hospitalization for a near-drowning event. A dermatologic exam revealed multiple small, tender, firm, chalky-white papules with surrounding erythema, in addition to two erythematous macules superior and medial to the papular lesions, corresponding to prior intraosseous access sites. The rash persisted despite trials of topical mupirocin and acyclovir cream, prompting a referral to a dermatologist. An excisional biopsy was performed, revealing circumscribed dermal deposits of acellular basophilic material connected to the overlying epidermis through an invaginated keratin plug. A von Kossa silver stain highlighted the deposits, confirming the diagnosis of perforating calcinosis cutis. The lesions did not recur following the excisional biopsy. Iatrogenic calcinosis cutis may be seen as a complication of the infusion of calcium-containing fluids via intraosseous access, in addition to the more commonly observed peripheral intravenous access. Awareness of this disorder is important in order to distinguish it from an infectious mimic and guide the selection of therapy.

Intravenous treatment of calcinosis cutis with sodium thiosulfate - A case series

Calcinosis cutis is defined as the deposition of calcium salts in the skin. The dystrophic form is the most common and usually occurs in chronic inflammatory processes associated with collagenoses. Therapeutic options include surgical excision as well as a few pharmacological treatments. Overall, the evidence for the known therapeutic interventions is very limited and there is a lack of valid recommendations. Intravenous sodium thiosulfate has been used successfully in the treatment of calciphylaxis. In our case series, five patients with dystrophic calcinosis cutis received intravenous sodium thiosulfate for at least six cycles on five consecutive days per month, with single doses of 12.5 g and 25.0 g, respectively. A reduction in the calcified lesions could not be proven with certainty, but stable disease conditions were achieved. Intravenous sodium thiosulfate may counteract the progression of calcinosis cutis. The successful use of epicutaneously applied sodium thiosulfate, as described in the literature, suggests that a higher cutaneous bioavailability can be achieved to exert a lytic effect on calcinosis cutis. This is further supported by the reported efficacy of high-dose sodium thiosulfate in the treatment of calciphylaxis.

Subepidermal calcified nodule (nodular calcinosis of Winer)

Subepidermal calcified nodule (SCN) is a clinical form of idiopathic calcinosis cutis, which commonly affects children, and presents as yellowish-white lesions involving the face. It is often misdiagnosed for other disorders like warts and molluscum contagiosum and treated by ablative procedures. In such a scenario, lack of histopathological examination makes it difficult to reach the correct diagnosis. We here report a case of SCN which was diagnosed after an excisional biopsy. Further, histopathological finding of dermal calcium deposits must prompt the clinician to rule out other disorders leading to calcinosis cutis, before labelling the case as SCN.

Extensive calcinosis cutis complicating radiotherapy

Dystrophic calcinosis cutis is a rare late sequela of radiotherapy, and can cause a significant impact on quality of life. Management of the condition can be challenging. However, we achieved effective symptomatic relief with injection of triamcinolone.

Eruptive syringomas associated with milia-like idiopathic calcinosis cutis

An 11-year-old boy presented generalized eruptive syringomas (ESs) associated with multiple milia-like whitish palmar papules corresponding to dermal calcium deposits. A relationship between calcium deposits distribution to an underlying eccrine duct was noted on pathology. The observation of dermal calcium deposits and its association with generalized ESs may support a possible sweat duct origin of this uncommon and peculiar form of superficial calcinosis cutis.

Cutaneous vascular calcifications in patients with chronic kidney disease and calcific uremic arteriolopathy: a cross-sectional study

INTRODUCTION

Calcific uremic arteriolopathy is a life-threatening cutaneous condition in patients with chronic kidney disease. Often, clinical diagnosis is accompanied by histopathologic evaluations demonstrating vascular calcium deposits. We aimed to investigate the presence of cutaneous calcifications in non-lesional tissue in patients with chronic kidney disease, and the relation to systemic vascular calcification.

METHODS

We investigated the presence of cutaneous vascular calcifications in non-lesional skin biopsies from patients with current or previous calcific uremic arteriolopathy and patients with different stages of chronic kidney disease without calcific uremic arteriolopathy, and explored their association with vascular calcification in other vascular beds. Systemic vascular calcification was examined by mammography and lumbar X-ray.

RESULTS

Thirty-nine adults were enrolled (current or previous calcific uremic arteriolopathy, n = 9; end-stage chronic kidney disease, n = 12; chronic kidney disease stage 3b-4, n = 12; healthy controls, n = 6). All calcific uremic arteriolopathy patients had end-stage kidney disease. Cutaneous vascular calcifications were not present in any of the non-lesional skin punch biopsies. Breast arterial calcification was demonstrated in patients with calcific uremic arteriolopathy (75%) and chronic kidney disease (end-stage 67% and stage 3b-4 25%, respectively), but in none of the controls. All chronic kidney disease patients had systemic calcification on lumbar X-ray (median score 21, 22, and 15 in patients with calcific uremic arteriolopathy, end-stage kidney disease and chronic kidney disease stage 3b-4). The serum calcification propensity was significantly different between groups.

DISCUSSION

Despite a high burden of systemic vascular calcification, cutaneous calcium deposits in non-lesional tissue could not be demonstrated histopathologically in patients with chronic kidney disease (with or without current or previous calcific uremic arteriolopathy). Further studies to determine whether these findings are representative or attributed to other factors are warranted.

Hard as stone: an exuberant form of calcinosis cutis

Dermatomyositis (DM) is an immune-mediated myopathy characterized by proximal skeletal muscle weakness, muscle inflammation, and distinct skin manifestations. Calcinosis cutis, involving the deposition of insoluble calcium salts in the soft tissues, affects approximately 8% of DM patients1 and poses significant treatment challenges. It can complicate with inflammation, ulceration, pain, and local and systemic infections, resulting in considerable morbidity. We present the case of a 69-year-old-woman with dermatomyositis who developed an exuberant form of calcinosis cutis.

Clinical course and potential associated factors of progressive calcinosis cutis in early systemic sclerosis: a cohort study

BACKGROUND

Calcinosis cutis of hands can progress and impair hand function in systemic sclerosis (SSc). Understanding the natural disease and comprehensive management is crucial.

OBJECTIVE

To examine clinical course and identify risk factors associated with progressive calcinosis cutis in early SSc.

METHODS

Dual time-point hand radiography was performed at initial and after diagnosis at median interval (range 2.9 ± 0.4 years) in 53 recruited patients with early SSc. Progressive calcinosis cutis defined as the worsening of severity according to simple soring scoring system (no, mild, moderate, severe) comparing to previous hand radiography. Odds ratio (OR) and their 95%CI were used to evaluate associated factors and calcinosis cutis progression.

RESULTS

A total of 35 cases (155 per 100 person-year), showed progressive calcinosis cutis with the incidence of 22.6 per 100-person-years (95%CI 16.2-31.4). The most common area of progressive calcinosis cutis was at right distal phalanx, 12 of 35 (22.6%). Although statistically not significant by logistic regression analysis, elderly patients, Raynaud's phenomenon, ischemic ulcer, telangiectasia, and salt-pepper tended to be more frequent in progressive calcinosis cutis than those who had no progression. Around one-quarter of those who had no calcinosis cutis experienced worsening across more than one level of severity.

CONCLUSION

Progression of calcinosis cutis in early SSc increased over time, particularly within 3 years after the first evaluation. Elderly patients and those with vasculopathy were found more frequently. Further study with a larger cohort is needed to support these findings.

Idiopathic calcinosis cutis of the buttocks: A case report and review of the literature

RATIONALE

Calcinosis cutis is a rare skin disease, and idiopathic cases are rarely reported. It is characterized by the deposition of insoluble calcium salts in the skin, subcutaneous tissue, superficial muscles, and tendon sheaths. However, no abnormal changes were found in the bone. In this article, we introduce a case of idiopathic calcinosis cutis of the buttocks with a long course and large lesion area.

PATIENT CONCERNS

A 51-year-old male patient was admitted to the hospital with a chief complaint of 'Due to the discovery of hard nodules with pruritus in the buttocks for 32 years. The patient was a male who was 51 years old. He has been in good health and reported no history of surgery, trauma, infection, metabolic disease, tumor, or other diseases. There was no family history. It is worth noting that the patient has the occupation of driving trucks, which keeps him sedentary.

DIAGNOSES

The accurate diagnosis of calcinosis cutis was confirmed by postoperative histopathological examination with many local calcifications and multinucleated giant cells in subcutaneous tissue.

INTERVENTIONS

The patient underwent skin lesion excision and autologous skin grafting under general anesthesia. A medium-thickness skin graft from the left lateral thigh was transplanted into the hip operation area, and a bolus tie-over pressure dressing was applied. After the operation, the patient received anti-infection treatment and was advised to rest in the prone position to prevent extrusion of the operation area.

OUTCOMES

The postoperative recovery was good, and there was no recurrence after 4 months of follow-up.

LESSONS

The incidence rate of cutaneous calcinosis is not clear. This patient had a large lesion area, long onset time, an invasion of the fat layer, and the onset site was located in the sacrococcygeal region. It is necessary to choose appropriate treatment methods.

Treatment of calcinosis cutis associated with autoimmune connective tissue diseases

Calcinosis cutis is a condition that is commonly associated with autoimmune connective tissue diseases. It is characterized by the deposition of insoluble calcium salts in the skin and subcutaneous tissue, which can cause pain, impair function, and have significant impacts on quality of life. Calcinosis cutis is difficult to manage because there is no generally accepted treatment: evidence supporting treatments is mostly comprised of case reports and case series, sometimes yielding mixed findings. Both pharmacologic and procedural interventions have been proposed to improve calcinosis cutis, and each may be suited to different clinical scenarios. This review summarizes current treatment options for calcinosis cutis, with discussion of recommendations based on patient-specific factors and disease severity.

Idiopathic calcinosis cutis in an infant: The importance of a wait-and-see approach

A healthy 2-year-old girl presented with multiple asymptomatic subcutaneous nodules on both legs. Histologically demonstrated calcium deposition within the dermis and subcutaneous tissue consistent with calcinosis cutis. Laboratory abnormalities, underlying genetic conditions, and potential triggering factors were ruled out. The lesions resolved over an 18-month period without treatment, emphasizing the importance of the wait-and-see approach in idiopathic cases of calcinosis cutis.

Updated solution for diagnosis and management of calcinosis cutis: A retrospective review

Calcinosis cutis is classified into 5 main types: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. However, it is occasionally misdiagnosed as a malignancy and its management remains challenging. Therefore, in this study, we report our diagnostic and treatment experiences with patients with calcinosis cutis and suggest strategies for improving patient care. This retrospective study included 7 patients (4 men, 3 women; 44.4 ± 32.0 years old) who visited our hospital between March 2013 and December 2022 and were diagnosed with calcinosis cutis through histopathological procedures. The patients underwent complete excision of the mass without a safety margin. Frozen biopsy was not performed during surgery. No significant intraoperative or postoperative complications were noted after the application of various imaging techniques for diagnosis and follow-up. All patients showed complete recovery. Follow-up showed no recurrence or complications in the 6 patients who completed 1 year of follow-up. Radiological tests such as plain radiography, ultrasonography, computed tomography, and magnetic resonance imaging are important for accurate diagnosis and treatment of calcinosis cutis. This approach can ensure precise assessment of preoperative lesions, leading to safe and less invasive patient treatment, recurrence prevention, and complications of calcinosis cutis.

Genital calcinosis cutis: Microscopic evidence supporting a dystrophic origin

Calcinosis cutis (CC) is characterized by the deposition of calcium salts in the skin and subcutaneous tissues. CC involving the vulva or foreskin (prepuce) is uncommon. We present a 9-year-old female with vulvar CC and a 15-year-old male with preputial CC. Microscopic review of excisional specimens revealed calcification associated with follicular cysts in the vulvar case and lichen sclerosus in the preputial case, suggesting a dystrophic origin to a subset of cases of genital CC that might otherwise be classified as idiopathic. The clinical implication of these findings is the need for close histopathologic scrutiny and ongoing clinical surveillance of patients with genital CC initially deemed idiopathic.

Subepidermal calcified nodule presenting as a cutaneous horn: two cases and a review of the literature

Subepidermal calcified nodules are an uncommon subtype of idiopathic calcinosis cutis. Morphologically, this entity typically present as a single, well-circumscribed, white-yellow nodule. Based on clinical appearance alone, subepidermal calcified nodules are frequently misdiagnosed and often requires histological confirmation. We describe two cases of subepidermal calcified nodules presenting atypically as cutaneous horns. Subepidermal calcified nodules presenting as a cutaneous horn has rarely been reported; on review, there are fewer than 10 such cases have been described within the past 30 years. The cases described here illustrate the clinical variety and should increase awareness of subepidermal calcified nodules presented.

Leg Ulceration with Infected Calcinosis Cutis Mimicking Osteomyelitis: A Case Report

Calcified tissue exposed in a leg ulcer can become infected and develop into a nidus of infection leading to sepsis. This case details a patient with a leg wound secondary to skin biopsy. This leg ulceration did not heal due to an underlying calcified mass and led to five hospital admissions for sepsis. She was diagnosed as having calcinosis cutis, which was suspected to be the source of her infections. The calcified mass was resected, and she healed uneventfully without further infections. Calcified soft-tissue masses should be considered in nonhealing leg ulcers and ulcers with multiple recurrent infections. Radiographs can be used to diagnose this condition, and surgical excision can be considered in cases of infection.

Neonatal iatrogenic calcinosis cutis caused by calcium gluconate extravasation

BACKGROUND

Calcium gluconate is widely used to treat neonatal hypocalcemia, severe hyperkalemia, and convulsions. However, extravasation of calcium gluconate can lead to iatrogenic calcinosis, causing symptoms such as local redness and swelling, cutaneous plaque, soft tissue calcification, and cutaneous tissue necrosis. Therefore, this study retrospectively analyzed the conservative treatment results of neonatal iatrogenic calcinosis.

METHODS

Data of neonates diagnosed with iatrogenic calcinosis cutis caused by calcium gluconate exudation between December 2012 and June 2021 were analyzed retrospectively. The clinical data included medical history, physical examination, laboratory findings, and radiographs. All the patients were conservatively treated, and the curative effect and prognosis were followed up by evaluating radiographs and limb function. Patients with complications, such as recurrence or limb dysfunction, were further followed up.

RESULTS

Overall, 16 neonates (sex: 10 male and 6 female infants; age: 17.5 ± 7.8 days) were included. Iatrogenic calcinosis cutis was located around the left wrist, right wrist, left ankle, and right ankle in four, one, six, and five patients, respectively. Calcification healed within 1-3 months (mean: 1.6 ± 0.6 months). After a follow-up of 0.5-8.5 years (mean: 3.5 ± 2.8 years), the appearance, joint function, local growth, and development of the lesion of the neonates with iatrogenic calcinosis cutis were consistent with those of the healthy ones.

CONCLUSION

For neonatal iatrogenic calcinosis cutis without cutaneous and subcutaneous tissue necrosis, symptomatic support treatment is effective and does not affect the limbs' appearance and function.Level of evidence: IV.

Neonatal Calcinosis Cutis After Treatment of Hypocalcemia with Calcium Gluconate: A Report of 2 Cases

BACKGROUND Calcium gluconate is used to treat neonatal hypocalcemia, severe hyperkalemia, and neonatal convulsions. Calcium gluconate can extravasate into the skin's soft tissues, resulting in redness, skin nodules, and calcification of soft tissue, which can cause tissue necrosis. This report presents 2 cases of neonatal calcinosis cutis following the treatment of hypocalcemia with calcium gluconate. CASE REPORT Case 1. The patient was a 12-day-old male neonate who presented with a mass in the right foot. He was recently discharged from the hospital after evacuation of subdual hematoma triggering his seizures. The swelling was associated with erythema but no discharge. His radiograph showed soft tissue calcification. He had received 2 peripheral intravenous calcium gluconate infusions to manage hypocalcemia during the last hospitalization. Symptomatic treatments were provided, and full resolution of the swelling was reported after 3 weeks. Case 2. The patient was a 1-month-old female infant newly diagnosed with cystic fibrosis who presented with a mass in her left foot. She underwent exploratory laparotomy in another hospital to manage meconium ileus. The mass was not mobile but there was no skin ulceration. Her radiograph showed soft tissue calcification. During her last admission, she had received 3 doses of intravenous calcium gluconate to manage hypocalcemia. The patient was observed and managed symptomatically. After 4 weeks, there was almost complete clinical and radiographic disappearance of the swelling without any skin necrosis. CONCLUSIONS This report has highlighted the importance of monitoring neonates treated with calcium gluconate who may develop skin rashes or nodules due to calcinosis cutis.

A novel presentation of calcinosis cutis of the scalp in adult dermatomyositis

Dystrophic calcinosis cutis is the aberrant deposition of insoluble calcium in cutaneous tissue generally secondary to inflammatory connective tissue disease. Although calcinosis cutis is commonly seen in juvenile dermatomyositis, it is a relatively rare occurrence in adult disease. Herein, we discuss an 82-year-old woman with extensive history of dermatomyositis of the scalp who presented with new-onset calcinosis cutis of the scalp.

Paediatric subepidermal calcified nodule of the ear

Subepidermal calcified nodules are benign entities that can be seen in the head and neck region and are part of a family of calcifying disorders known as calcinosis cutis, in which calcium is deposited in subcutaneous tissue. We describe a middle aged childhood boy with a rapidly enlarging ear mass of unknown aetiology who presents for otolaryngologic evaluation. In this case, surgical excision provided both definitive diagnosis and sufficient treatment. Although uncommon, it is important to recognise these lesions in order to appropriately counsel patients on management options and rule out underlying disorders that may be responsible for the pathology.