Case 3: Surgical Management of Soft Tissue Calcium Deposition in the Lower Limbs: A Case Report
Keywords: Calcinosis cutis, calcium deposits; debridement; excision.
Authors: K. Kaushal (MD), L. McClymont (MD) and K. Munro (MD). Dundee, Scotland
The purpose of this case study is to describe the surgical treatment of idiopathic ulcerative cutaneous calcinosis or calcinosis cutis of the lower extremity. We present a case of an 85-year-old Scottish female who presented to our service with no significant medical history but with areas of soft tissue ulceration and infection in the right lower leg secondary to ectopic/idiopathic calcium deposition. The underlying cause of her calcium deposition is still under investigation by the medical team. At the time of evaluation, 1 of the nodules on the anterio-medial aspect of the right lower was ulcerated and became infected with unknown aetiology, which lead to cellulitis of this limb. She initially underwent minimal debridement and subsequent near circumferential excision of calcium deposit and skin graft reconstruction. During her second procedure, intra-operative ultrasound scanning was utilised to demonstrate the depth of the calcium deposit and specimen was submitted to pathology. Pathologic examination diagnosed the submitted specimen as cutaneous calcinosis. At recent follow up, the patient was well with improvement in her symptoms in the right leg. The wound remained healed 17 months postoperatively without any issues or complications.
Before and after
Patient examination
Patient’s right leg was erythematous, oedematous and tender. Distal pulses were palpable. Sensation was intact and had satisfactory active range of movements of the joint above and below. There were areas of skin breakdown on the right anterior shin and circumferential stony hard skin texture with underlying evident calcium deposits and nodules. There was no history of injury, trauma, or insect bite to the area. The patient reported a fever on the first to second day, minimal chills, and no shivers or sweats. The patient denied nausea, vomiting, and dizziness. The patient reported that the pain was present throughout the day and that it was achy and burning and is 7/10 on the pain scale. The patient stated that the pain is worse on palpation and walking and worsened dependent on the position. No history of similar symptom and no history of vascular disease, smoking, drinking, or drugs were reported by the patient. The patient reported no recent travel, and there were no sick contacts. The patient had no areas of rash or redness, and there was no erythema on any other part of body other than the lower extremities.
Pre-Operative Considerations
Tests to rule out factors contributing to the accumulation of calcium in soft tissues secondary to disordered calcium homeostasis like end stage renal disease, inflammation, malignancy and genetic conditions were ordered: 1) Complete blood count to rule out for lupus erythematosus and possible malignant neoplasms 2) Urea and Creatinine to rule out chronic kidney failure. 3) Parathyroid hormone and vitamin D level are done to rule out hyperparathyroidism and hypervitaminosis D. 4) Calcium, phosphate, total proteins, albumin, 24 h urine excretion of calcium/inorganic phosphate levels to rule out metastatic calcification. 5) Creatine phosphokinase (CPK), lactate dehydrogenase (LDH), glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT), and aldolase levels to rule out dermatomyositis. 6) Antinuclear antibodies (ANA), anti-dsDNA, and anti-ENA to rule out lupus and systemic sclerosis. 7) Bicarbonate and arterial pH to rule out milk and alkali syndrome. Other studies included x-ray, skin ultrasound.
Step 1: Pre-op X-ray
Plain film tibia/fibula radiographs of the right lower extremity was ordered and showed sheets of soft tissue calcifications, with both linear and nodular configurations, particularly abundant in the lower half of the calf, with a circumferential distribution, mainly in the subcutaneous pannus.
Step 2: X-ray specimen
Post operative X-ray of the specimen – Calcinosis cutis right lower leg
Step 3: Ultrasound image of right lower leg
During the second procedure, intraoperative ultrasound scanning was utilised to demonstrate the depth of the calcium deposit. Ultrasound scanning is a non-invasive investigation which may help guide the surgical planning by providing detail about the extent and depth of the calcium deposition.
Step 4: Excision – 1
Image showing excision of large confluent calcium plaque above the deep fascia prior to grafting
Step 5: Excision – 2
Image showing excision of large confluent calcium plaque above the deep fascia prior to grafting
Step 6: The defect after excision of disease
Image showing the defect after removal of calcinosis cutis for planning of harvesting of split thickness skin graft.
Step 7: Calcinosis cutis
Excised large confluent calcium plaque
Step 8: Wound bed ready for grafting
The image showing the disease free wound bed ready for skin graft.
Step 9: Graft check
The graft healing with no issue.
Post-Operative Plan
The patient had undergone four surgical interventions under our plastic surgery services, which included 2 surgical debridements with negative- pressure therapy and 2 final surgical procedures of split thickness skin grafting. She remained an in patient until her first graft checks and was followed up biweekly in the clinics run by our specialist nurses. She healed well with no complications.
- The radiologist plays a critical role in avoiding unnecessary invasive procedures and in guiding the selection of appropriate tests that can result in a conclusive diagnosis of calcinosis cutis.
- The treatment is challenging and depends on the cause. The key is to avoid trauma, smoking cessation, decrease stress and exposure to the cold. Smaller lesions have been reported to respond to warfarin, ceftriaxone, and intravenous immunoglobulin (IVIG). Surgical excision and carbon dioxide laser can also be used. Larger lesions respond to diltiazem, bisphosphonates, probenecid, aluminium hydroxide, and surgical excision or curettage. Patients with small and localized lesions are good candidates for surgical treatment whereas more generalized disease will require medical management. The outcomes for most patients are guarded because the condition has no cure.
References
- 1. Jiménez-Gallo D, Ossorio-García L, Linares-Barrios M. Calcinosis Cutis and Calciphylaxis. Actas Dermosifiliogr. 2015 Dec;106(10):785-94. [PubMed] 2. Huang HL, Wu WT, Ou TT. Extensive calcinosis cutis universalis in a patient with systemic lupus erythematosus: 10-year treatment experience. Kaohsiung J Med Sci. 2014 Dec;30(12):639-40. [PubMed] 3. Valenzuela A, Chung L. Calcinosis: pathophysiology and management. Curr Opin Rheumatol. 2015 Nov;27(6):542-8. [PubMed] 4. Solanki A, Narang S, Kathpalia R, Goel A. Scrotal calcinosis: pathogenetic link with epidermal cyst. BMJ Case Rep. 2015 Sep 23;2015 [PMC free article] [PubMed] 5. Prabhu R, Sarma YS, Phillip K, Sadhu S. Diffuse idiopathic calcinosis cutis in an adult: a rare case. Eurasian J Med. 2014 Jun;46(2):131-4. [PMC free article] [PubMed] 6. Reiter N, El-Shabrawi L, Leinweber B, Berghold A, Aberer E. Calcinosis cutis: part I. Diagnostic pathway. J Am Acad Dermatol. 2011 Jul;65(1):1-12; quiz 13-4. [PubMed] 7. Reiter N, El-Shabrawi L, Leinweber B, Berghold A, Aberer E. Calcinosis cutis: part II. Treatment options. J Am Acad Dermatol. 2011 Jul;65(1):15-22; quiz 23-4. [PubMed] 8. Gunasekera NS, Maniar LEG, Lezcano C, Laga AC, Merola JF. Intralesional Sodium Thiosulfate Treatment for Calcinosis Cutis in the Setting of Lupus Panniculitis. JAMA Dermatol. 2017 Sep 01;153(9):944-945. [PubMed] 9. García-García E, López-López R, Álvarez-Del-Vayo C, Bernabeu-Wittel J. Iatrogenic Calcinosis Cutis Successfully Treated with Topical Sodium Thiosulfate. Pediatr Dermatol. 2017 May;34(3):356-358. [PubMed] 10. Li G, Adachi JD, Cheng J, Thabane L, Hudson M, Fritzler MJ, Lorenzi S, Baron M, Larché M., Canadian Scleroderma Research Group. Relationship between calcium channel blockers and skin fibrosis in patients with systemic sclerosis. Clin Exp Rheumatol. 2017 Sep-Oct;35 Suppl 106(4):56-60. [PubMed]