Calcinosis Cutis Confined to the Dermis after Intravenous Administration of a Calcium Preparation: A Case Report and Review of the Japanese Literature
A 61-year-old Japanese woman presented with induration on the left forearm. The family history was not remarkable. The medical history included bladder cancer diagnosed 10 weeks earlier, which was resected surgically. Inadvertently, the left iliac artery was occluded during the operation. This was treated intraoperatively by common iliac artery bypass and intravenous infusion of 2% calcium chloride into the arm vein to induce vasoconstriction. Postoperatively, no extravasation of the injected preparation was noted on the arm, but a red flare appeared around the area of administration. The red flare gradually led to induration and ulcer formation. The patient was referred to the Department of Dermatology at postoperative week 7 for further management.\nPhysical examination showed an indurated plaque of 13 × 65 mm with linearly distributed ulcers covered by yellowish-white material, and the entire lesion was surrounded by reddish skin (fig. ). Laboratory data showed BUN 25.2 mg/dl (normal: 7.0–22.0), serum creatinine 0.97 mg/dl (normal: 0.3–0.8), serum calcium 9.3 mg/dl (normal: 8.0–10.5), serum phosphate 4.4 mg/dl (normal: 4.0–6.0), and high sensitivity-parathyroid hormone 460 pg/ml (normal: 160–520). Cultures were negative for acid-fast bacilli and fungi.\nTwo skin biopsy samples were obtained from the left forearm. The histopathological findings were similar in the two specimens and included deposition of basophilic amorphous substance in the upper and middle dermis (fig. ), but not in the subcutis. The amorphous material was eliminated transepithelially, with partial defect of the epidermis and substitution with crust. There was granulomatous infiltration surrounding the amorphous material with underlying collagen accumulation. Histiocytic infiltrates intermingled with lymphocytes and giant cells among the collagen fibers (fig. ). The amorphous substance stained black with von Kossa staining (fig. ). Based on the above clinical and histopathological findings, the final diagnosis was calcinosis cutis. The whitish chalky substance disappeared gradually within 1 month, together with healing of the ulcers within 2 months, with scar formation (fig. ).