Photo ROUNDS

Fang-Yih Liaw, MD; Ching-Fu Huang, MD; Erythematous plaque with Chien-Ping Chiang, MD, PhD yellowish papules on the shin Department of Family and Community Health (Dr. Liaw) Was the eruption on our patient’s leg related to the and Department of Dermatology (Drs. Huang treatment he received during his hospitalization? and Chiang), Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

A 53-year-old man with a 10-year history of acute renal failure with and [email protected] poorly controlled hypertension was brought was treated with furosemide, glucose, and Department EDITOR to our emergency department (ED) because insulin. He also received parenteral Richard P. Usatine, MD he’d had a sudden loss of consciousness. The gluconate, also via the long saphenous vein University of Texas ED physicians discovered a spontaneous in- in his left leg. Health Science Center at San Antonio tracranial hemorrhage in his brainstem with One week later, while still in the ICU, the fourth ventricle compression and immedi- patient developed an erythematous plaque The authors reported no potential conflict of interest ately transferred him to the intensive care with several firm yellowish papules on his relevant to this article. unit (ICU). lower left leg (FIGURE). During the patient’s hospitalization, he was treated for ventilator-associated pneu- monia and a gastric ulcer with cefepime 1 g ● What is your diagnosis? IV 3 times daily and esomeprazole 40 mg/d IV via the long saphenous vein of his lower ● how would you TREAT THIS left leg. The patient subsequently developed PATIENT?

Figure Erythematous plaque with firm yellowish papules on the shin P ho t o cour o t esy of: of: esy F ang- Y ih ih L ia w , , MD

jfponline.com Vol 62, No 7 | July 2013 | The Journal of Family Practice 375 PHOTO ROUNDS

Dx: Iatrogenic tensor surfaces of the extremities. High serum Calcinosis cutis is characterized by calcifica- triglyceride levels confirm this diagnosis. tion of the skin and subcutaneous tissue. It is z In gouty tophus, hyperuricemia is a categorized into 5 major types based on the key risk factor. Patients initially present with etiology: dystrophic, metastatic, idiopathic, extreme pain and swelling in a single joint— , and iatrogenic.1 especially the first metacarpophalangeal. results from local tissue injury inducing al- When left untreated, the pain and swelling terations in collagen, subcutaneous fat, and may extend to the soft tissue of other articular elastic fibers. Typically, the ectopic calcifi- joints and the auricular helix. Hard yellowish cation mass consists of amorphous calcium to whitish papulonodules with an erythema- phosphate and hydroxyapatite. Serum levels tous halo may also appear. A histopathologic of calcium and phosphate in these patients examination will reveal granulomatous in- are typically in the normal range.2 flammation surrounding yellow-brown urate Iatrogenic calcification typically occurs in crystals; in contrast, you will see deposits of patients who have received IV calcium chlo- blue calcium phosphate with calcinosis cutis.2 ride or calcium gluconate therapy.2 When ex- travasation of calcium gluconate occurs, the A conservative approach to treatment venipuncture site can rapidly become tender, There is no consensus on the management of warm, and swollen, with erythema and whit- calcinosis cutis, although it is typically man- Radiographs are ish papuloplaques; in severe cases, signs of soft aged conservatively.5 Progressive clearing of initially negative, tissue necrosis or infection may also be seen.3 the calcification often occurs spontaneously but can show The lesions appear about 13 days after the in- 2 to 3 months after onset, with no evidence of changes one to fusion of calcium gluconate.4 Radiographs are tissue calcification after 5 or 6 months.6 When 3 weeks after initially negative, but can show changes one to calcinosis cutis is complicated by serious ex- the initial 3 weeks after the skin lesions appear.4 travasation injuries, such as secondary infec- appearance of z Not always obvious. Iatrogenic calci- tion or skin necrosis, debridement, drainage, the skin lesions. nosis cutis is easy to diagnose when a mas- or skin grafting may be needed. sive extravasation of calcium infusion is followed by tender, swollen whitish papulo­ Our patient’s road to recovery plaques with surrounding erythema and skin Our patient was transferred to the respiratory necrosis.3 The diagnosis can be more chal- care unit after he was stabilized. His lesions lenging when the extravasation is not obvi- improved gradually, without any treatment. ous. In such cases, a thorough history and One month after being hospitalized, he was careful exam will help distinguish it from 3 discharged to an assisted living facility. JFP other conditions in the differential diagnosis. CORRESPONDENCE Chien-Ping Chiang, MD, Department of Dermatology, Tri-Ser- vice General Hospital, No. 325, Sec. 2, Chenggong Road, Neihu District, Taipei City 114, Taiwan (ROC); [email protected] Distinguishing calcinosis cutis from these conditions The differential diagnosis includes cellulitis, eruptive xanthoma, and gouty tophus. References 1. Walsh JS, Fairley JA. Calcifying disorders of the skin. J Am Acad z Patients with cellulitis will complain of Dermatol. 1995;33:693-706. areas of increased warmth, tenderness, red- 2. Walsh JS, Fairley JA. Cutaneous mineralization and ossifica- tion. In: Wolff K, Goldsmith LA, Katz SI, et al, eds. Fitzpatrick’s ness, and swelling. Constitutional symptoms Dermatology in General Medicine. 7th ed. Columbus, Ohio: such as fever, chills, and tachycardia may also McGraw-Hill;2007:1293-1296. 3. Goldminz D, Barnhill R, McGuire J, et al. Calcinosis cutis fol- be present. Laboratory results will reveal leu- lowing extravasation of calcium chloride. Arch Dermatol. kocytosis and elevated erythrocyte sedimen- 1988;124:922-925. 4. Sonohata M, Akiyama T, Fujita I, et al. Neonate with calcinosis tation rate and C-reactive protein levels. cutis following extravasation of calcium gluconate. J Orthop z Eruptive xanthoma affects patients Sci. 2008;13:269-272. 5. Reiter N, El-Shabrawi L, Leinweber B, et al. Calcinosis cutis: with hypertriglyceridemia with a sudden onset part II. J Am Acad Dermatol. 2011;65:15-22. of monomorphous erythematous to yellowish 6. Ramamurthy RS, Harris V, Pildes RS. Subcutaneous calcium deposition in the neonate associated with intravenous admin- papules over the buttocks, shoulders, and ex- istration of calcium gluconate. Pediatrics. 1975;55:802-806.

376 The Journal of Family Practice | July 2013 | Vol 62, No 7