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| CASE REPORT |
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| Year : 2019 | Volume
: 3
| Issue : 4 | Page : 147-149 |
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X-ray and ultrasound findings in calcinosis cutis
Abhinav Aggarwal1, Nidhi Bhatnagar2, Akshay Kapila2, Preeti Sharma2, Ankit Dubey2
1 Department of Diagnostic and Interventional Radiology, Heart Center, University of Leipzig, Leipzig, Germany
2 Department of Radiology, Mata Chanan Devi Hospital, New Delhi, India
| Date of Submission | 10-Dec-2018 |
| Date of Acceptance | 26-Dec-2019 |
| Date of Web Publication | 26-Dec-2019 |
Correspondence Address:
Dr. Abhinav Aggarwal
Department of Diagnostic and Interventional Radiology, Heart Center, University of Leipzig, Leipzig
Germany
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/LJMS.LJMS_65_18
Deposition of calcium and phosphorus in cutaneous or subcutaneous tissues is termed as calcinosis cutis. Clinical presentation extends from induration of skin to nodular swellings. The clinical presentation can lead to formulation of faulty diagnosis like infective etiology. Use of imaging modalities is often required to formulate correct diagnosis. We describe two cases of calcinosis cutis occurring in neonates.
Keywords: Calcinosis cutis, sonography, wrists
How to cite this article:
Aggarwal A, Bhatnagar N, Kapila A, Sharma P, Dubey A. X-ray and ultrasound findings in calcinosis cutis. Libyan J Med Sci 2019;3:147-9 |
| Introduction | |  |
Deposition of calcium and phosphorus in the soft tissues (i.e., skin, dermis, muscles, periarticular tissues, and rarely visceral organs) is termed as calcinosis cutis.[1] It is often misdiagnosed as infection in neonates, leading to prolonged faulty treatment. Clinical features generally consist of fever, pain, inflammation, and acute tenderness.[2] Multiple causes have been listed as differential diagnosis. We present two cases of subcutaneous calcification in neonates with their radiographic and ultrasound findings. To our knowledge, radiographic and ultrasonographic findings have not been described together before for this pathology in radiology literature.
| Case Reports | | |
Case 1
A gravida 5, para 2, preterm baby girl of 13 days of age presented with swelling over both the wrists and ankles. The baby was born at 33 weeks and 5 days to a mother who had developed peripartum cardiomyopathy in cardiac failure with pregnancy-induced hypertension. The child herself had developed pneumonitis in the right lung on the 1st day after birth and had become jittery over the next 3 days. Along with the various antibiotics, the child was also given injectable calcium gluconate to correct serum calcium levels. Congenital hypothyroidism was excluded. Serum calcium was also normal. The baby was sent for radiographs of both the wrists in view of bilateral wrist swellings. Calcific densities were seen in the soft tissues involving the wrist predominantly on the radial aspect [Figure 1]. Complementary ultrasound of the wrists showed extensive subcutaneous linear hyperechoic lesions with distal acoustic shadow suggestive of calcification [Figure 2]. Injectable calcium gluconate was thought to be the cause of deposition of subcutaneous calcium in this patient. | Figure 1: Anteroposterior radiographs of both the wrists of the patient showing abnormal calcification in the wrists on both radial and ulnar aspects. It is more extensive in the left wrist (Case 1)
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 | Figure 2: Ultrasound image of the left wrist on the dorsal aspect showing calcification as hyperechoic to other subcutaneous tissues, giving a distal acoustic shadow (Case 2)
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Case 2
A 27-day-old male baby was admitted with the complaints of swelling over both the wrists, more on the right side. Blood investigations revealed serum calcium levels to be 3.32 mg/dl (normal range: 4–4.8 mg/dl). Serum parathyroid hormone levels were also significantly increased at 151.1 pg/ml (normal range: 11.1–79.5 pg/ml). The baby was sent for radiographs of both the wrists in view of bilateral wrist swellings. Calcific densities were seen in the soft tissues involving the right wrist predominantly on the radial aspect with fine linear extensions proximally along the distal aspects of the right radius and ulna [Figure 3]. Complementary ultrasound of the wrists and extensive subcutaneous calcification were seen again on ultrasound [Figure 4] and [Figure 5]. The baby was diagnosed with congenital hyperparathyroidism and treated conservatively. | Figure 3: Anteroposterior radiograph of the right wrist of the patient showing irregular-shaped calcification in the wrist, more extensive on the radial aspect
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 | Figure 4: Ultrasound image of the right wrist showing calcification as hyperechoic to other subcutaneous tissues, giving a distal acoustic shadow. Radius bone (RAD) and its epiphysis (EP) are also marked
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 | Figure 5: Ultrasound image of the right wrist on the volar aspect showing a large blob/mass of calcification, giving a distal acoustic shadow
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| Discussion | | |
Calcinosis cutis was first described by Virchow as early as 1855.[2],[3] The etiopathogenesis of calcinosis cutis is multifactorial. Various causes mentioned in literature include repeated attempts to insert peripheral venous line, extravasation of solutions in soft tissues causing local tissue damage, and temporary elevations of serum and/or soft-tissue calcium. These cause phlebitis, coagulative necrosis, and clotting within blood vessels, resulting in precipitation of salts and fat cell necrosis, leading to deposition of calcium compounds within skin/soft tissues.[2] Various other rarer causes of calcinosis cutis present in literature are brown fat necrosis, pseudohypoparathyroidism, and autoimmune connective tissue disorders.[3],[4],[5],[6] Calcinosis cutis occurring without any known cause is also described in literature and termed as idiopathic calcinosis cutis.[2] In our cases, one baby was diagnosed to have congenital primary hypoparathyroidism, whereas the other baby developed calcinosis cutis due to extravasation of calcium gluconate. Both these conditions are known to cause calcinosis cutis in neonates.[7],[8],[9] Deposits of hydroxyapatite crystals of calcium phosphate in skin can present as nodules in neonate patients, causing ulcers.[9] The most common differential diagnosis based on clinical presentation of these patients is infective etiology. Formulation of correct diagnosis in these cases is not possible without radiological investigations primarily involving radiographs and ultrasound.[2],[9] This can help in preventing the baby from being administered with unnecessary antibiotics.[2]
Radiographs have been the mainstay of imaging investigations for musculoskeletal pathologies in children for a long time.[1],[3],[6] The role of ultrasound in diagnosing the musculoskeletal pathologies in neonates and infants is not extensively described in literature with very few publications related to the same.[10]
We suggest that in suspected musculoskeletal pathologies in neonates and children, a combination of radiographs and sonography should be adopted to achieve early and optimum diagnosis. With advances in ultrasound, we may exclude the need for radiographs in future exempting the child from radiation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Arora A, Agarwal A, Kumar S, Gupta SK. Iatrogenic calcinosis cutis – A rare differential diagnosis of soft-tissue infection in a neonate: A case report. J Orthop Surg (Hong Kong) 2005;13:195-8.  |
| 2. | Dhar D, Varghese TP. Idiopathic soft tissue calcification in an extremity: A case report. Oman Med J 2013;28:131-2. |
| 3. | Higgins JN, Haddock JA, Shaw DG. Case report: Soft tissue and perivisceral calcification occurring in an infant: A case of brown fat necrosis. Br J Radiol 1993;66:366-8. |
| 4. | Mantovani G. Clinical review: Pseudohypoparathyroidism: Diagnosis and treatment. J Clin Endocrinol Metab 2011;96:3020-30. |
| 5. | Shahi V, Wetter DA, Howe BM, Ringler MD, Davis MD. Plain radiography is effective for the detection of calcinosis cutis occurring in association with autoimmune connective tissue disease. Br J Dermatol 2014;170:1073-9. |
| 6. | Golden ET, Dickson P, Simoneaux S. Brown fat necrosis with calcifications in the newborn: Risk factors, radiographic findings, and clinical course. Indian J Radiol Imaging 2018;28:107-10. [ PUBMED] [Full text] |
| 7. | Aslan Y, Gedik Y, Okten A, Aksoy A, Cimşit G, Ari N, et al. Congenital primary hypoparathyroidism presented with extensive cutaneous and subcutaneous calcifications. Turk J Pediatr 1999;41:253-7. |
| 8. | Aktas S, Turkyilmaz C, Unal S, Ergenekon E. Calcinosis cutis mimicking infection in a preterm infant. Ann Pediatr Child Health 2015;3:1077. |
| 9. | Puvabanditsin S, Garrow E, Titapiwatanakun R, Getachew R, Patel JB. Severe calcinosis cutis in an infant. Pediatr Radiol 2005;35:539-42. |
| 10. | Keller MS. Musculoskeletal sonography in the neonate and infant. Pediatr Radiol 2005;35:1167-73. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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