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Calcinosis Cutis Mimicking Infection in a Preterm Infant

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Calcinosis Cutis Mimicking Infection in a Preterm Infant Central Annals of Pediatrics & Child Health Case Report *Corresponding author Selma Aktas, Gazi University Hospital, Department of Pediatrics, Newborn Medicine, Ankara, Turkey, Tel: 90 Calcinosis Cutis Mimicking 312 202 65 53; Fax: 90 312 202 94 94; Email: Submitted: 29 June 2015 Infection in a Preterm Infant Accepted: 21 August 2015 Published: 24 August 2015 Selma Aktas*, Canan Turkyilmaz, Sezin Unal and Ebru Ergenekon Copyright Department of Pediatrics and Neonatology, Gazi University Hospital, Turkey © 2015 Aktas et al. OPEN ACCESS Abstract Iatrogenic calcinosis cutis presents with similar symptoms and signs of soft tissue, Keywords joint and bone infections. We present here a preterm infant with iatrogenic calcinosis • Calcinosis cutis cutis misdiagnosed as septhic arthritis and osteomyelitis. We hope that our case report • Newborn helps to raise clinicians’awareness of this rare situation. .When swelling and erythema • Calcium gluconate of extremities occur in a newborn infant after intravenous calcium infusion, iatrogenic calcinosis cutis should be considered after rulling out local infections ABREVATIONS 1). Renal and lower extremity doppler USG; renal, hip and knee n-CPAP: nasal Continuous Positive Airway Pressure; IV: left lower extremity was noticed on fifth day postnatally (Figure IntraVenous; MR: Magnetic Resonance Imaging; PPROM: 2) were done to differentiate thrombosis, septic arthritis and Prolonged Premature Rupture Of Membranes; RDS: Respiratory osteomyelitis.joint USG and plainAll were radiograph reported of asleft normal. lower extremity Complete (Figure blood Distress Syndrome count, serum C-reactive protein, procalcitonin, liver and renal INTRODUCTION function tests were unremarkable. We could not rule out infection clinically so ampicillin and amikacin were stopped Neonatal hypocalcemia is a common problem of preterm and piperacillin tazobactam and vancomycin were begun. infants and intravenous (IV) calcium gluconate has been widely Despite antibiotherapy; swelling, tenderness and erythema of used for treatment [1]. When extravasation of calcium gluconate occurs; swelling, erythema, signs of soft tissue necrosis or piperacillin tazobactam treatment, vancomycin was discontinued andthe leftclindamycin extremity was continued. added to On piperacillin the fifth day tazobactam of vancomycin because and of calcinosis cutis [2]. We present a preterm infant diagnosed the possibility of abscess and osteomyelitis, Magnetic resonance infection may be seen. Rarely local calcification appears, called iatrogenic calcinosis cutis, mimicking infection. The aim of this imaging (MR) of the leg was done and reported as normal. Then case report is to raise clinicians’ awareness of this rare situation. CASE PRESENTATION plain-radiograph was repeated 10 days after the first plain A female infant was born at 33 weeks to a 33 years-old gluconatefilm and it was showed injected the calcinosisvia peripheral cutis venousof left lowercatheter extremity of left gravida 2, parity 2 mother via cesarean section 30 days after lower(Figure extremity 3). Then toretrospectively treat hypocalcemia it was (ionized noticed Ca: that 0.74 IV mmol/l,calcium rupture of membranes. Her birth weight was 2140 grams (50th percentile for gestational age). At 27 weeks of gestation cervix preterm delivery antenatal steroid therapy was given to mother atwas the cerclaged same gestational because ofage. cervical Additionally insufficiency. sulbactam Due ampicillinto risk of was given to mother because of prolonged premature rupture of membranes (PPROM) 10 days before delivery. Preterm infant was accepted to Neonatal Intensive Care Unit due to prematurity and tachypnea. A catheter was insterted into umbilical artery. Chest x-ray and arterial blood gas analysis were unremarkable. She was ventilated under nasal Continuous Positive Airway Pressure (n-CPAP) with 30% oxygen for respiratory distress syndrome (RDS). Antibiotic therapy (ampicillin-amikacin) was begun because of PPROM, preterm birth and RDS. On the second day of life n-CPAP was stopped and two days later umbilical arterial catheter was removed. Swelling and erythema of the Figure 1 Sweling and erythema of the left leg of infant. Cite this article: Aktas S, Turkyilmaz C, Unal S, Ergenekon E (2015) Calcinosis Cutis Mimicking Infection in a Preterm Infant. Ann Pediatr Child Health 3(7): 1077. Aktas et al. (2015) Email: Central 2 hours to 24 days) [5]. Mu et all studied 103 hypocalcemic neonates who were administered IV calcium gluconate, and the mean period before signs of calcinosis cutis appeared was 7.7 days (range from 5 to 11 days) [6]. Plain radiography is gold standard for diagnosis but are initially negative because calcium usually appear with in 1-3 weeks [4,6]. In the present case, local signssolutions (swelling used andtherapeutically erythema) appeared are radiolucent. three days X-ray after findingscalcium radiograph of patient was totally normal, 10 days after calcium gluconate administrationadministration x-rayand extravasation. showed calcinosis While cutis. first Thus plain it is compatible with the literature brown to white papules or nodules. The lesion can be tender, Manifestations of calcinosis cutis may be firm, erythamatous, Figure 2 X-ray of the left leg of the infant, before calcification. andwarm nodules. and fluctuant [3,5]. In the present case initially the lesion was firm, tender and erythamatous; then it became white papules cutis disappear with in 2-6 months [7]. Similarly our case the lesionThe cicatrised clinical and at radiographicthe age of findings4 months. of iatrogenic The pathogenesis calcinosis of calcinosis cutis caused by extravasation of IV calcium is degeneration and soft tissue necrosis [8]. To prevent this complication, IV 10% calcium gluconate should be diluted to a maximum concentration of 50 mg/ml. A central line should be Figure 3 X-ray of the left-leg, extraosseous calcifications. serum Ca:6.7 mg/dl) on the second day of life. Although no Figure 4 Erythema and induration of left leg of the infant. severe extravasation was noticed at that time, the diagnosis of iatrogenic calcinosis cutis due to calcium gluconate therapy was made,. Serum calcium, phosphorus and alkaline phosphatase levels were repeated, and serum parathyroid hormone level was checked to exclude hyperparathyroidism, all the results were normal. Antibiotherapy was stopped. Initially the local lesion was firm, tender and erythamatous, then it became white papule and noduleDISCUSSION (Figure 4,5). Inflamation resolved over 3 weeks. Iatrogenic calcinosis cutis occurs due to extravasation of IV calcium infusions such as calcium gluconate and calcium chloride during treatment of neonatal hypocalcemia [3]. If extravasation of calcium is massive, signs of inflamation occur very early but if severalextravasation days after is mild extravasation inflamation of signs calcium, may mean be less 13 markeddays (range and Figure 5 White nodule of the left leg of the infant. calcification is delayed [4]. Signs of inflamation usually appear Ann Pediatr Child Health 3(7): 1077 (2015) 2/3 Aktas et al. (2015) Email: Central the preferred way for IV calcium infusion. If a patient needs IV calcium bolus, it should be administered slowly at a maximum Roentgenol Radium Ther Nucl Med. 1975; 123: 845-849. calcifications after intravenous injections of calcium gluconate. Am J rate of 2 ml/minute and its use with anions like bicarbonate, 2. Tuncer S, Aydin A, Erer M. Extravasation of calcium solution leading to phosphate and sulphate should be avoided. Subcutaneous and calcinosis cutis surrounding the dorsal cutaneous branch of the ulnar intramuscular routes should not be used to avoid tissue necrosis. Ca Gluconate is preferred to Cachloride because the calcium is 3. nerve. J Hand Surg Br. 2006; 31: 288-289. less likely to precipitate. If extravasation of calcium gluconate Castells A. Childhood calcinosis cutis. Pediatr Dermatol. 1996; 13: is suspected; the catheter must be removed immediately. Cold 114-117.Rodríguez-Cano L, García-Patos V, Creus M, Bastida P, Ortega JJ, pacs should be applied for 15 minutes four times a day to treat 4. edema at extravasation sites and limb elevation for 48 hours is suggested [9]. Lee FA, Gwinn JL. Roentgen patterns of extravasation of calcium 5. gluconate in the tissues of the neonate. J Pediatr. 1975; 86: 598-601. Serious complications of extravasation of calcium gluconate Am Acad Dermatol. 1992; 26: 1015-1017. Sahn EE, Smith DJ. Annular dystrophic calcinosis cutis in an infant. J are skin necrosis and secondary infection. In these cases 6. mechanical debridement or skin graft should be needed [1,10]. injections in tetany of the newborn. Arch Pediatr. 1936; 53: 215–23. Tumpeer IH, Denenholz EJ. Calcium deposit following therapeutic 7. Soon SL, Chen S, Warshaw E, Caughman SW. Calcinosis cutis as a measures are recommended. Needle aspiration is rarely useful There is no specific treatment of calcinosis cutis, supportive care to differentiate it from a pyogenic abscess [1]. Misdiagnosis 138: 778. of cellulitis, arthritis, pyogenic abscess, osteomyelitis and complication of parenteral calcium gluconate therapy. J Pediatr. 2001; 8. Severe calcinosis cutis in an infant. Pediatr Radiol. 2005; 35: 539-542. cases [5]. In the present case thrombosis, septic arthritis, Puvabanditsin S, Garrow E, Titapiwatanakun R, Getachew R, Patel JB. osteomyelitisthromboflebitis andare notabscess uncommon were insuspected neonatal calcinosisinitially cutisand 9. antibiotherapy was begun. 184-186.Millard
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