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Uremic tumoral calcinosis with atypical manifestation. Case report
Calcinosis tumoral urémica con manifestación atípica. Reporte de caso
Arbey Aristizabal-Alzatea, John Fredy Nieto-Ríosa,b,
, Daniela Trujillo-Agudeloc, Dahyana Cadavid-Aljurea, Lina María Serna-Higuitad, Gustavo Zuluaga-Valenciaa
Corresponding author
a Departamento de Nefrología y Trasplante Renal, Hospital Pablo Tobón Uribe, Medellín, Colombia
b Sección de Nefrología, Departamento de Medicina Interna, Universidad de Antioquia, Medellín, Colombia
c Departamento de Medicina Interna, Universidad Pontificia Bolivariana, Medellín, Colombia
d Universidad Eberhard Karls, Instituto de Epidemiología Clínica y Biometría Aplicada, Tuebingen, Alemania
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Reporte de caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 534 "Ancho" => 750 "Tamanyo" => 53698 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Photo of the patient's hand, with swelling in the distal phalanges of the fingers.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tumoral calcinosis (TC) is a disease characterized by deposits of calcium phosphate crystals in soft tissues. The TC observed in patients with chronic kidney disease (CKD) is known as uremic tumoral calcinosis (UTC).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Below we present the case of a patient with terminal CKD, who presented calcification in the periarticular soft tissues of the fingers, which is an unusual manifestation of UTC.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This is a 48-year-old woman with terminal CKD due to polycystic kidney disease, on peritoneal dialysis for 3 years. The patient consulted for a 6-month history of symptoms which consisted of an increase in the size of the distal phalanx of the second and third fingers of the right hand, distal phalanx of the second finger of the left hand (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and a palpable mass on the right shoulder. The patient reported pain and itching at the site of the lesions, plus a non-fetid white discharge. The X-rays showed thick, amorphous calcifications of the periarticular soft tissues, compatible with TC (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The laboratory tests revealed tertiary hyperparathyroidism documented with parathyroid hormone values of 2362<span class="elsevierStyleHsp" style=""></span>pg/ml, albumin of 3.2<span class="elsevierStyleHsp" style=""></span>g/dl, phosphorus of 9.7<span class="elsevierStyleHsp" style=""></span>mg/dl and corrected calcium of 10.2<span class="elsevierStyleHsp" style=""></span>mg /dl. Parathyroid scintigraphy revealed hyperplasia of the 4 parathyroid glands. The patient underwent a parathyroidectomy of 3 glands, with a favorable evolution and a significant decrease in the lesions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">TC is a rare disease, characterized by periarticular lesions of variable size, which involves small and large joints, leading to serious deformities, joint stiffness and functional impotence. They can also induce ulcerative lesions, allowing the transdermal elimination of calcific or milky material, as in the case described.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">TC is secondary to the presence of minimal repetitive trauma and a reparative inflammatory process. Apparently, trauma favors the calcinosis process by activating mechanisms that lead to hemorrhage, fat necrosis, fibrosis, collagenization, collagenolysis and, finally, calcification.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Movement and friction are believed to be important in the formation of the adventitial bursa of periarticular location<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>; the bursa subsequently fills with calcified material, predominantly hydroxyapatite.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the case described, calcinosis occurred in a patient with terminal CKD on peritoneal dialysis, who presented hyperparathyroidism with a marked alteration in phosphorus-calcium metabolism, and therefore we are dealing with a case of UTC. The prevalence of UTC in hemodialysis patients has been reported to be between 0.5-1.9%.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> CKD patients have several factors that can predispose to soft tissue calcification, the most important is an increase in the calcium-phosphorus product. The incidence of TC is high when the calcium-phosphorus product is greater than 55.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Radiological evaluation has a key role in diagnosis. On plain radiographs, TC has an opaque and nodular appearance.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Computed tomography and magnetic resonance imaging help to determine the extent of the lesions. Scintigraphy (methylene diphosphonate-technetium 99) is of great value in detecting multiple lesions, new lesions in formation, bone marrow involvement and to monitor therapy, since it reflects the activity of the lesions.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most of the literature on TC describes that the location of lesions is around large joints.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The specific manifestation presented in the case here described, with involvement of the distal phalanx of the fingers, generating a striking bulge, is not frequently described in the literature. Regarding the treatment of CTU, several strategies have been proposed, with preference for medical management over surgical management. Since the most important pathogenic factor is the increase in the calcium-phosphorus product, the reduction of serum phosphorus represents a non-invasive and fundamental approach to therapy. Patients with hyperphosphatemia should receive phosphate binders. It has been suggested that daily dialysis with low calcium in the dialysate or daily dialysis at night could reduce TC.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> If hyperparathyroidism is present, parathyroidectomy has led to rapid resolution of lesions in some patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding surgical treatment, this is only used when the response to other treatments is insufficient. In the case described, tertiary hyperparathyroidism with hyperphosphatemia was demonstrated and it was decided to perform a parathyroidectomy. Surgical resection of the lesions was not considered in accordance with the recommendations in the literature. Post-surgical evolution was adequate, with improvement in calcinosis lesions in the patient's last follow-up.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In all uremic patients with periarticular calcifications, the diagnosis of TC should be considered; therefore, in these patients we recommend evaluating phosphorus-calcium metabolism, ruling out the presence of hyperphosphataemia and hyperparathyroidism, and treating these underlying conditions as the treatment of choice.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Aristizabal-Alzate A, Nieto-Ríos JF, Trujillo-Agudelo D, Cadavid-Aljure D, Serna-Higuita LM, Zuluaga-Valencia G. Calcinosis tumoral urémica con manifestación atípica. Reporte de caso. Nefrologia. 2022;42:221–222.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 534 "Ancho" => 750 "Tamanyo" => 53698 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Photo of the patient's hand, with swelling in the distal phalanges of the fingers.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 498 "Ancho" => 750 "Tamanyo" => 53121 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">X-ray of the patient's hands, with calcifications in the distal phalanges that had the hump.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reversal of uremic tumoral calcinosis by optimization of clinical treatment of bone and mineral metabolism disorder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 57 | 43 | 100 |
| 2024 September | 83 | 38 | 121 |
| 2024 August | 68 | 65 | 133 |
| 2024 July | 56 | 40 | 96 |
| 2024 June | 48 | 52 | 100 |
| 2024 May | 69 | 42 | 111 |
| 2024 April | 46 | 39 | 85 |
| 2024 March | 64 | 30 | 94 |
| 2024 February | 50 | 49 | 99 |
| 2024 January | 51 | 29 | 80 |
| 2023 December | 50 | 22 | 72 |
| 2023 November | 71 | 31 | 102 |
| 2023 October | 66 | 47 | 113 |
| 2023 September | 63 | 40 | 103 |
| 2023 August | 72 | 28 | 100 |
| 2023 July | 63 | 44 | 107 |
| 2023 June | 78 | 25 | 103 |
| 2023 May | 74 | 39 | 113 |
| 2023 April | 45 | 34 | 79 |
| 2023 March | 61 | 30 | 91 |
| 2023 February | 50 | 36 | 86 |
| 2023 January | 62 | 33 | 95 |
| 2022 December | 88 | 46 | 134 |
| 2022 November | 86 | 47 | 133 |
| 2022 October | 98 | 76 | 174 |
| 2022 September | 67 | 53 | 120 |
| 2022 August | 69 | 45 | 114 |
| 2022 July | 58 | 54 | 112 |
| 2022 June | 81 | 58 | 139 |
| 2022 May | 61 | 47 | 108 |
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