CASE 8455 Published on 07.08.2011

Iatrogenic neonatal calcinosis cutis

Section

Paediatric radiology

Case Type

Clinical Cases

Authors

Arora A1, Jain V2, Bhutani R3

(1) Department of Radiodiagnosis, Institute of Liver & Biliary Sciences, New Delhi, India
(2) Department of Neonatology, Fortis Hospital, Shalimar Bagh, New Delhi, India
(3) Department of Radiodiagnosis, La-Femme Fortis Hospital, New Delhi, India

Patient

24 days, male

Clinical History
This preterm neonate was discharged from ICU on day-8 following treatment for respiratory distress, which included intravenous calcium-gluconate adminsitration. On day-14 post-discharge he developed a unilateral hard-swelling in the left leg. He was otherwise asymptomatic. During his hospital stay, he had an intravenous cannula in the same limb, though no history of fluid-extravasation.
Imaging Findings
The neonate was subjected to plain radiographs of the lower limbs, which showed linear extraosseous calcification extending from the level of knee joint to the ankle. The underlying bones appeared normal. The contralateral limb was normal.

Based upon the imaging findings and relevant clinical history, a diagnosis of neonatal calcinosis cutis was considered. Although there was no clinical history of fluid extravasation at the time of the hospital stay, there could have been a mild subclinical fluid-extravasation, which was probably overlooked. Moreover, this condition is recognised without a history of extravasation of intravenously administered calcium solution. The child was managed conservatively and the hard palpable swelling regressed gradually. No functional deficit was recorded.
Discussion
Calcinosis cutis is a term used to describe abnormal deposition of calcium in the skin. Calcinosis cutis can be classified into 4 major types according to aetiology: dystrophic, metastatic, iatrogenic, and idiopathic. Dystrophic calcification is the commonest and occurs in the setting of normal serum calcium and phosphate levels. It is characterised by abnormal calcium deposition in previously damaged, inflamed or traumatised tissues. Metastatic calcinosis is usually a late complication of chronic renal failure arising from increased serum calcium and/or phosphate levels. Idiopathic calcinosis is when calcinosis occurs in the absence of a known tissue injury or systemic metabolic defect. Iatrogenic calcinosis cutis takes place secondary to a treatment or procedure such as repeated heel sticks in the newborn, extravasation of calcium gluconate, parenteral administration of calcium or phosphate, subcutaneous injection of calcium-containing heparin and prolonged use of calcium-containing electrode paste. The exact pathogenesis of iatrogenic calcinosis cutis appears to be multifactorial. It can occur even without extravasation of intravenously administered calcium solution.

Iatrogenic neonatal calcinosis cutis is usually seen in small for gestational age (SGA) as well as preterm neonates who are frequently treated with intravenous infusion of calcium gluconate for neonatal hypoglycemia. The extravasated calcium solution incites an inflammatory reaction of the skin and subcutaneous soft tissues. Histologically, the deposited calcium within the skin and subcutaneous soft tissues leads to degeneration of the dermal collagen and lymphohistiocytic cell infiltration. The clinical manifestations develop within days to weeks (average time interval is 13 days) following extravasation and are frequently mistaken for cellulitis, abscess and osteomyelitis, especially when the lesion is tender, warm and fluctuant. It can also present a firm, non-tender swelling of the affected limb. Erythematous, consisting of white to brown papules or nodules and bullous lesions have also been reported. Radiological changes usually become obvious in 1–3 weeks time. Three different radiological forms have been reported: (1) diffuse subcutaneous plaques; (2) an amorphous mass localised to the site of extravasation, associated with or without periostitis; and (3) a vascular or perivascular line of calcification. The radiographic findings are of immense importance and help in clinching the correct diagnosis, which may not be otherwise suspected.

No treatment is required for neonatal calcinosis cutis, except for supportive conservative management. Usually the calcification starts to clear within 2–3 months, resolving completely after 5–6 months. Most infants recover without functional deficit.
Differential Diagnosis List
Iatrogenic calcinosis cutis
Final Diagnosis
Iatrogenic calcinosis cutis
Case information
URL: https://www.eurorad.org/case/8455
DOI: 10.1594/EURORAD/CASE.8455
ISSN: 1563-4086

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