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Dystrophic Calcification and a Snake in the Grass

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Dystrophic Calcification and a Snake in the Grass Injury Extra (2005) 36, 537—541 www.elsevier.com/locate/inext CASE REPORT Dystrophic calcification and a snake in the grass Nihar Ranjan Padhi a,*, Poonam Padhi a, Lisa Choudhrie b, Naveen Eipe c a Department of Orthopedics, Padhar Hospital, Padhar, Betul, Madhya Pradesh 460005, India b Department of Pathology, Padhar Hospital, Padhar, Betul, Madhya Pradesh 460005, India c Department of Anesthesia, Padhar Hospital, Padhar, Betul, Madhya Pradesh 460005, India Accepted 11 May 2005 Case history tive, and serum calcium level that was within accep- table limits. The chest radiograph was normal. A 45-year-old farmer presented with discharging sinii He was clinically diagnosed to have chronic osteo- of the left leg, 5 years after snakebite at the same myelitis of the left fibula probably secondary to the site. The snake had been identified as a non-poiso- snakebite. He was scheduled to undergo curettage nous wolf snake and the tissues then had developed a and debridement of the sinii. localised inflammatory reaction. These symptoms Under spinal anaesthesia and a pneumatic tour- resolved completely within a fortnight and the niquet, an incision was made over the anterolateral patient was well for the intervening period. Six compartment of the left leg extending over most of months ago, he developed fever and a painful swel- the length. Within the anterior group of muscle, ling in the same leg. A general practitioner treated sheets of calcified tissues were found (Fig. 2). These him with antibiotics and he recovered. Tw o weeks were intermingled with the fascial planes. The tibial before presentation he developed discharging sinii of and fibular surfaces were free of any involucrum or the left leg and was referred to us for expert ortho- new bone. There was little pus within the tissues. paedic evaluation. On examination, he was found to The cavity created by debridement was extensively have a firm tender swelling over the anterolateral curetted and irrigated before closure. aspect of the left leg and two discharging sinii prox- The post-operative X-ray (Fig. 3) showed clear- imal to his lateral malleolus. He was afebrile and did ance of the diffuse opacity in the left leg. The no have any regional enlargement of his lymph nodes. wound healed satisfactorily and the patient was The rest of his examination was normal. discharged on the 5th post-operative day. X-ray (Fig. 1) showed diffuse new bone formation Histopathological examination of the excised tis- around the fibular diaphysis. sue was reported as dystrophic calcification and Laboratory investigations revealed a total leuko- necrosis with acute inflammatory processes. The cyte count of 13,000/dl with a normal differential patient has been advised regular follow-up. and an erythrocyte sedimentation rate (ESR at 60 min) of 46 mm. Other investigations included a peripheral blood smear for sickling, which was nega- Discussion * Corresponding author. Tel.: +91 7141 263346; fax: +91 7141 263346. This patient suffered from snakebite on the left leg. E-mail address: [email protected] (N.R. Padhi). Till he presented to us, he seemed to have recov- 1572-3461 # 2005 Elsevier Ltd. Open access under CC BY-NC-ND license. doi:10.1016/j.injury.2005.05.010 538 N.R. Padhi et al. Figure 1 Pre-operative X-ray of left leg showing irregular opacification around the fibular diaphysis. Figure 2 Intraoperative photograph showing abnormal bone in the interosseous space. Dystrophic calcification and a snake in the grass 539 Figure 3 Post-operative X-ray of left leg showing clearance of opacity around the bone. ered completely from its effects without any signs or charging sinii at the same site of the snakebite. symptoms suggestive of chronic tissue injury. Osteomyelitis is the most frequent cause of dischar- The lower limb is the most common site of injury ging sinii. Other causes of discharging sinii described due to snakebite.23 Unlike poisonous snakes where include foreign body reaction,3 salmonella osteo- systemic envenomation and its effects predominate, myelitis,1 coccidioidomycosis,28 fungal osteomyeli- in non-poisonous snakes there is a preponderance of tis22 and Madura mycetoma or foot.7 localised injury. Common in the early period are A clinical diagnosis of osteomyelitis was made and bleeding from painful punctured or lacerated confirmed by the X-ray, which showed features wounds, oedema, and compartment syndrome.6 Late typical of that disease except for the location. This presentations include non-healing ulcers, tissue patient’s X-ray (Fig. 1) revealed diaphyseal new necrosis and rarely gangrene or narcotising fascitis.2 bone formation. Osteomyelitis is typically located These commonly resolve with adequate primary in the metaphysis of long bones16 and, therefore, treatment. Long-term sequelae described are rare, other causes were also considered. Diaphyseal and amongst them of orthopaedic interest include lesions are seen in tuberculosis of the bone4,31 chondrolysis and joint destruction12 or malignant and due to Salmonella infection.25 Sy et al. 27 change in non-healing (Marjolin’s) ulcers.18 describe two patients with a combination of sickle This patient was well (except for the acute epi- cell disease and fluorosis who presented with similar sode 6 months ago) till he presented with the dis- diaphyseal cortical thickening and accumulation of 540 N.R. Padhi et al. necrotic bone. Both these diseases are frequently sarcoma. They conclude that though the radio- seen in this part of India. graphic and magnetic resonance imaging (MRI) fea- A neoplastic process was also considered. This tures of the two conditions were similar, the was unlikely because of the history of trauma, age of appropriate management was very different. the patient and the presentation (with a discharging This case reports dystrophic calcification pre- sinus). Diaphyseal neoplasm have been reported in senting clinically as chronic osteomyelitis–—a rare osteosarcoma,21 Ewing’s sarcoma,8 solitary bone complication of snakebite. Orthopaedic surgeons plasmacytoma,30 metastatic bone disease,10 aneur- may have other patients presenting with similar ysmal bone cysts,13 Langerhans’ cell histiocytosis,14 discharging sinii following trauma-mimicking osteo- unicameral bone cysts,17 Ribbing disease,24 giant myelitis. Infection in dystrophic calcification should cell tumor,9 adamantinoma5 and primary skeletal be considered as a differential for such presenta- non-Hodgkin’s lymphoma.29 tions. Of these, osteosarcoma could present with radio- These are rare sequelae of snakebite and to our graphic features seen in our patient–—long-bone knowledge have not been reported previously. diaphyseal location, mixed areas of lysis and sclero- sis, cortical destruction and periosteal new bone formation. An MRI would have aided the diagnosis by delineating the site and extent of the lesion, but this References is an expensive investigation and as in our case, unavailable in many parts of the developing world. 1. Andrianopoulos EG, Lautides G, Papachristos I, Papaefthi- Operative exploration, curettage and biopsy, miou O. Salmonella osteomyelitis of the rib. Scand Cardio- including tissue culture (for tuberculosis and vasc J 1998;32(3):181—2. salmonellosis) and histopathological examination, 2. Angel MF, Zhang F, Jones M, et al. Necrotizing fasciitis of the upper extremity resulting from a water moccasin bite. South followed by appropriate antimicrobial pharma- Med J 2002;95:1090—4. cotherapy are the recommended treatments for 3. Arora A, Agarwal A. Dhaga syndrome: a previously unde- 11 chronic osteomyelitis . The operative findings scribed entity. J Bone Joint Surg Br 2004;86:282—4. (Fig. 2) of new bone-like tissue within the inteross- 4. Basanagoudar PL, Gupta PN, Bahadur R, Dhillon MS. Tuber- eous membrane were unexpected. The histopathol- culosis of the clavicle presenting as an expansile lytic lesion: a case report. Acta Orthop Belg 2001;67:505—9. ogy was reported as dystrophic calcification with 5. Bohndorf K, Nidecker A, Mathias K, et al. The radiological necrosis. findings in adamantinoma of the long tubular bones. Rofo Dystrophic calcification is the presence of cal- Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr cium within non-viable or dying tissues and this has 1992;157:239—44 [article in German]. been described in many ‘traumatized’ tissues. 6. Cawrse NH, Inglefield CJ, Hayes C, Palmer JH. A snake in the clinical grass: late compartment syndrome in a child bitten by Numerous reports of dystrophic calcification follow- an adder. Br J Plast Surg 2002;55:434—5. ing surgery, joint replacement and tendon repair 7. Corr P. Clinics in diagnostic imaging (26). Madura foot (or 20 exist in literature. Rho et al. have reported a case mycetoma). Singapore Med J 1997;38:268—9. of a healthy 2-year-old boy with a calcified nodule 8. Eggli KD, Quiogue T,Moser Jr RP.Ewing’s sarcoma. Radiol Clin on the heel secondary to a single heel stick in the North Am 1993;31:325—37. 9. Fain JS, Unni KK, Beabout JW, Rock MG. Nonepiphyseal giant neonatal period. Dystrophic cutaneous calcification 15 cell tumor of the long bones. Clinical, radiologic, and patho- may arise at sites of local trauma. Kanda et al. logic study. Cancer 1993;71:3514—9. have described two cases of gluteal gigantic dys- 10. Frassica FJ, Frassica DA. Metastatic bone disease of the trophic calcinosis cutis caused by a large number of humerus. J Am Acad Orthop Surg 2003;11:282—8. subcutaneous and/or intramuscular injections. 11. Hashmi MA, Norman P, Saleh M. The management of chronic osteomyelitis using the Lautenbach method. J Bone Joint While trauma is the most commonly described cause Surg Br 2004;86:269—75. of dystrophic calcification, infection has also been 12. Hofmeister EP, Shin AY, Boswell P. Chondrolysis and joint implicated. The role of nanobacteria, which are destruction secondary to snake envenomation. Am J Orthop capable of precipitating calcium salts, is, however, 2001;30:649—51.
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