SICOT e-Newsletter

Issue No. 9 - June 2009

Case of the Month

Six-year-old girl presented with bilateral hip swellings. The swellings have been gradually increasing in size over 1 year, but the constitutional symptoms of fever, warmth and tenderness over the swellings have been present for 1.5 months with increasing pain. ESR was 95/140. X-rays show the following (Figs. 1a & 1b):

 Fig. 1a    Fig. 1b

What is your diagnosis?

  1. Soft Tissue Tumour
  2. Infection with calcific deposits
  3. Tumoral Calcinosis
  4. Milk-Alkali Syndrome
  5. HyperVitaminosis D
  6. Calcinosis Universalis
  7. Metastatic Calcification
  8. Heterotopic ossification

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A diagnosis of Tumoral Calcinosis was made, but with possible supervening infection. Aspiration showed a thick chalky material like white pus, and the analysis showed a few pus cells. Serum Calcium and Phosphorous levels were normal. A trial of medical treatment with antacids and systemic antibiotics was initiated for 10 days with no response.

Surgery was undertaken to excise the affected tissues, showing chalky material with devitalized muscle tissues (Fig. 2).

 Fig. 2

This was done on one side followed by the other 2 weeks later, due to the relatively high blood loss intra-operatively. She was transfused 2 units after the first procedure and 1 unit after the second.

Follow-up 4 weeks post surgery showed complete resolution of the Lesion. The patient is on phosphorus diet restriction and antacids (Fig. 3).

Fig. 3

The etiology of Tumoral Calcinosis is unknown, although there is some evidence suggesting an inborn abnormality of phosphorus metabolism. In this condition, deposits of calcium salts occur in the extra-capsular soft tissues around joints.

Commonest sites: around the hips, elbows and shoulders.

Laboratory findings may be normal or slightly elevated: Normal renal and parathyroid function, Normal or slightly elevated serum calcium, phosphorus, uric acid and phosphatase.

Investigations show calcified deposits which appear white on CT and dark on MR – either study may demonstrate fluid-fluid levels within some of these masses.

Treatment is by surgical excision of the masses, but recurrence is common with incomplete excision. Dietary phosphorus restriction and phosphate binding antacids (aluminium hydroxide) may be effective. The following are phosphorus rich foods and best avoided or reduced:

  • milk and milk products
  • whole grains, including bread, crackers, cereal, rice and pasta
  • dried beans, peas and lentils
  • organ meats, including liver, tongue, kidney, heart and giblets
  • nuts and seeds, including peanut butter and other nut butters
  • chocolate and other candies made with milk, such as caramels
  • cola soft drinks

Author:
Dr Hatem Galal Said
Assistant Professor Orthopedics and Trauma Department
Assiut University Hospital, Egypt
hatemgalal@yahoo.com