Metastatic calcinosis cutis in end-stage renal disease Victoria A. Jaeger, DO, Megan G. Newman, MD, and Curtis R. Mirkes, DO
Alterations in calcium and phosphorus levels and joint pain are a common occurrence in end-stage renal disease patients. However, metastatic calcinosis cutis is a rare diagnosis that often combines these two findings, with extensive soft tissue calcification surrounding a large joint being the hallmark of this disease. The exact mechanism behind this clinical entity is unknown. The treatment and complications can be severe and disabling. Here, we discuss the case of a 26-year-old man presenting with unusually advanced skin and joint calcification of the shoulders, neck, hand, and penis.
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alcinosis cutis is an unusual disorder characterized by large calcium phosphate deposition into cutaneous and subcutaneous tissues. Five subtypes of calcinosis cutis exist: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. The shoulders, elbows, and hips are typically the joints affected by these lesions. However, cases have been reported in various other periarticular areas of the body (1). Patients present with symptoms such as pain, joint stiffness, nerve compression, inflammation, fistula formation, infection, and sometimes systemic symptoms such as fever (1, 2). Presenting skin findings may be nodules with extrusion of a chalky while substance. Here, we describe a patient who presented with advanced metastatic calcinosis cutis with multiple lesions of the large joints, neck, hands, and penis. CASE REPORT A 26-year-old man with a history of focal segmental glomerulosclerosis and a congenital solitary kidney presented with left hand pain and fatigue. He had been treated for presumed gout affecting the left hand 12 days prior to presentation at the emergency department without resolution of his symptoms. He appeared cachectic and ill, with multiple areas of calcium deposits on the left hand, left shoulder, right axilla (Figure 1), and penis. The left third digit was swollen with calcific deposits and nodules. The dorsal and left lateral penile shaft had hard, nontender nodules without swelling. Initial laboratory values were a calcium level of 9.7 mg/dL, phosphorus level of 10.6 mg/ dL, parathyroid hormone level of 5646 pg/mL, creatinine of 7.60 mg/dL, blood urea nitrogen of 124 mg/dL, and estimated glomerular filtration rate of 8.8 mL/min/1.73 m2. Computed
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tomography without intravenous contrast showed extensive, lobulated soft tissue calcifications in both shoulders and the left chest wall, extending into the neck (Figure 2). Findings were consistent with metastatic calcinosis cutis secondary to chronic kidney disease stage 5. Hemodialysis, cinacalcet, a renal diet, and phosphate binders were started. A calcium-phosphate product
Alterations in calcium and phosphorus levels and joint pain are a common occurrence in end-stage renal disease patients. However, metastatic calcinosis cutis is a rare diagnosis that often combines these two findings, with extensive soft tissue calcification surrounding a large joint being the hallmark of this disease. The exact mechanism behind this clinical entity is unknown. The treatment and complications can be severe and disabling. Here, we discuss the case of a 26-year-old man presenting with unusually advanced skin and joint calcification of the shoulders, neck, hand, and penis.
C
alcinosis cutis is an unusual disorder characterized by large calcium phosphate deposition into cutaneous and subcutaneous tissues. Five subtypes of calcinosis cutis exist: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. The shoulders, elbows, and hips are typically the joints affected by these lesions. However, cases have been reported in various other periarticular areas of the body (1). Patients present with symptoms such as pain, joint stiffness, nerve compression, inflammation, fistula formation, infection, and sometimes systemic symptoms such as fever (1, 2). Presenting skin findings may be nodules with extrusion of a chalky while substance. Here, we describe a patient who presented with advanced metastatic calcinosis cutis with multiple lesions of the large joints, neck, hands, and penis. CASE REPORT A 26-year-old man with a history of focal segmental glomerulosclerosis and a congenital solitary kidney presented with left hand pain and fatigue. He had been treated for presumed gout affecting the left hand 12 days prior to presentation at the emergency department without resolution of his symptoms. He appeared cachectic and ill, with multiple areas of calcium deposits on the left hand, left shoulder, right axilla (Figure 1), and penis. The left third digit was swollen with calcific deposits and nodules. The dorsal and left lateral penile shaft had hard, nontender nodules without swelling. Initial laboratory values were a calcium level of 9.7 mg/dL, phosphorus level of 10.6 mg/ dL, parathyroid hormone level of 5646 pg/mL, creatinine of 7.60 mg/dL, blood urea nitrogen of 124 mg/dL, and estimated glomerular filtration rate of 8.8 mL/min/1.73 m2. Computed
368
tomography without intravenous contrast showed extensive, lobulated soft tissue calcifications in both shoulders and the left chest wall, extending into the neck (Figure 2). Findings were consistent with metastatic calcinosis cutis secondary to chronic kidney disease stage 5. Hemodialysis, cinacalcet, a renal diet, and phosphate binders were started. A calcium-phosphate product
