Between a Rock and a Hard Place: Tumoral Calcinosis in a Dialysis Patient

1University of California San Francisco, San Francisco, CA
2University of California San Francisco, San Francisco, CA

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 197

Case Presentation:

A 54‐year old African American man with history of dialysis‐dependent renal failure secondary to diabetes, presented with a large, painful swelling in his right buttock. Three years ago, his primary physician noted it as a small soft‐tissue calcification that has progressively increased in size until it was impairing his ability to walk, sit, or even use the toilet comfortably. He presented to hospital with worsening pain, and a exam revealed a rock‐hard tender ovoid mass in the posterior thigh with limited range of motion of the hip joint. The rest of the exam was unremarkable. Labs showed secondary hyperparathyroidism, with an iPTH of 1358 pg/mL (normal: 10–60 pg/mL), normal serum calcium, and hyperphosphatemia (range 6‐9 mg/dL). Plain films showed a large calcified mass (22 × 14 × 15 cm) in the right posterior thigh, and a diagnosis of tumoral calcinosis was made (Figure 2). Because of the size of the mass and its proximity to the neurovascular tissues, surgical excision was considered too high risk at this late stage, and he underwent subtotal parathyroidectomy. On follow‐up his iPTH had normalized, but it remains to be seen whether parathyroidec‐tomy results in any improvement of his tumoral calcinosis.

Figure 1. Large mass in right posterior thigh.

Figure 2. X‐ray of right lower extremity showing large calcified mass.

Discussion:

Secondary hyperparathyroidism is commonly seen in dialysis‐dependent patients but in rare situations can lead to tumoral calcinosis, a tumor‐like deposition of calcium‐phosphate crystals within the periarticular soft tissue and most commonly found as multiple lesions around hip, shoulder, and elbow. Elevated calcium‐phosphorus product (>65‐75), trauma, secondary hyperparathyroidism, and African American race are risk factors for uremic tumoral calcinosis. Radiographs typically show a calcified mass with tabulated appearance surrounding a joint and histology shows densely loculated calcific debris and fluid enclosed by fibrous tissue. Tumoral calcinosis can cause joint pain, motion range limitation, fistula formation, and infection. Surgical resection to restore function and control symptoms can be attempted, but recurrence is common. Other available treatment modalities include low phosphate diet, phosphate chelators, subtotal parathyroidectomy, and renal transplantation.

Conclusions:

Hospitalists often defer treatment of secondary hyperparathyroidism and hyperphosphatemia in dialysis patients to outpatient care. As this case demonstrates, inattention to the long‐term consequences of these common metabolic conditions can lead to debilitating complications. Physicians should be vigilant about correcting the calcium‐phosphorus product in dialysis patients.

Author Disclosure:

A. Singh, none; M. Fang, none.

To cite this abstract:

Singh A, Fang M. Between a Rock and a Hard Place: Tumoral Calcinosis in a Dialysis Patient. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 197. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/between-a-rock-and-a-hard-place-tumoral-calcinosis-in-a-dialysis-patient/. Accessed May 22, 2019.

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