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Year : 2020  |  Volume : 63  |  Issue : 1  |  Page : 140-141
Idiopathic calcinosis cutis in a young male: A cytological diagnosis with histopathological correlation


Department of Lab Medicine, Max Lab, Max Super Speciality Hospital, 1 Press Enclave Road, Saket, New Delhi, India

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Date of Web Publication31-Jan-2020
 

How to cite this article:
Arya A, Shelgaonkar G, Bhatti SS, Kumar D, Das P. Idiopathic calcinosis cutis in a young male: A cytological diagnosis with histopathological correlation. Indian J Pathol Microbiol 2020;63:140-1

How to cite this URL:
Arya A, Shelgaonkar G, Bhatti SS, Kumar D, Das P. Idiopathic calcinosis cutis in a young male: A cytological diagnosis with histopathological correlation. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Feb 17];63:140-1. Available from: http://www.ijpmonline.org/text.asp?2020/63/1/140/277368




Calcinosis cutis is a term used to describe a group of disorders characterized by deposition of calcium salts in the skin and subcutaneous tissue. Virchow initially described calcinosis cutis in 1855.[1] Calcinosis cutis is classified into four major types according to etiology: dystrophic, metastatic, iatrogenic, and idiopathic.[1] Dystrophic calcinosis is calcification associated with infection, inflammatory processes, cutaneous neoplasm, or connective tissue diseases.[2],[3] Metastatic calcification results from elevated serum levels of calcium or phosphorus.[4] Iatrogenic and traumatic calcinosis are those types which are associated with medical procedures.[4] Idiopathic calcinosis cutis is cutaneous calcification of unknown cause with normal serum calcium, no history of local tissue injury and systemic metabolic disorder.[5] Subepidermal calcified nodule and tumoral calcinosis are idiopathic forms of calcification. A few rare types have been variably classified as dystrophic or idiopathic.[6] These include calcinosis cutis circumscripta, calcinosis cutis universalis, tumoral calcinosis, and transplant-associated calcinosis cutis.[6] Calcinosis cutis with Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia is referred to as CREST syndrome.[7],[8],[9] Here, we present a case of idiopathic calcinosis cutis over back in a 17-year-old young male along with the histopathological correlation.

A 17-year-old male came to the surgery OPD with a subcutaneous nodular swelling in the lower back region [Figure 1]a of 10 years duration. The swelling was insidious in onset and had gradually increased to the present size. There was no history of trauma or any underlying disorder. A clinical diagnosis of soft tissue tumor was made and fine needle aspiration cytology (FNAC) was advised. On examination, the swelling was multinodular, firm to hard with whitish specks and measured 2.0 × 2.0 cm. FNAC of the lesion was difficult as the swelling was hard and yielded chalky white granular material [Figure 1]b. Both air dried and wet fixed smears were made and stained with May–Grünwald Giemsa (MGG) stain and Papanicolaou stain (Pap), respectively. The Giemsa stained smears showed crystals along with pinkish amorphous granular material and [Figure 1]c and Papanicolaou stained smears revealed crystals associated bluish amorphous granular material [Figure 1]d.
Figure 1:(a) Nodular swelling with whitish specks on lower back. (b) Whitish granular material spread over the slide. (c) Amorphous pink deposits admixed with crystals of calcium (Pap, 1000×). (d) Calcium crystals admixed with amorphous bluish deposits (MGG, 1000×) with black crystals of calcium in inset (Von Kossa, 1000×). (e) Overlying epithelium with nests of calcified material separated by fibrous septa in the dermis (H and E, 400×)

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Subsequently, the smears were stained with Von Kossa silver stain which stained the calcium deposits black [Figure 1]d, Inset]. Based on these cytological findings, a diagnosis of calcinosis cutis was suggested and correlation with serum calcium and histopathological examination was advised for definitive characterization.

Further investigations done for serum calcium, phosphorus, alkaline phosphatase, and parathormone levels were within normal limits. The patient underwent surgical excision of nodule followed by histopathological examination. The gross specimen showed an irregular lesion measuring 2.0 × 2.0 cm. On sectioning, the lesion was gritty with chalky white calcified areas. Representative sections were taken and stained with H and E stain. Sections showed nests of calcified material separated by fibrous septa in the dermis without any significant inflammation [Figure 1]e. The overlying epithelium was normal. In view of the above findings, a final diagnosis of calcinosis cutis was given.

Calcinosis cutis is a cutaneous condition characterized by localized and organized deposition of calcium in the skin first described by Virchow in 1855. It is very important to correctly classify and subtype these lesions so that the correct treatment can be initiated. Most lesions of calcinosis cutis that develop gradually are asymptomatic.

The history and evolution of the lesions depend on the etiology of the calcification. The patients with dystrophic calcification may provide a history of an underlying disease, a preexisting dermal nodule (which represents a tumor), or an inciting traumatic event. The patients with metastatic calcification most frequently have a history of chronic renal failure. Serum calcium and phosphate levels remain normal in dystrophic calcification, whereas it is abnormal in metastatic calcification. Those who develop iatrogenic calcinosis cutis generally have a history of recent hospitalization.[4]

The cases of idiopathic calcinosis cutis are usually not associated with previous trauma, disease, recent hospitalization. In the present case, the patient did not have any history of trauma or underlying disease.

FNAC samples yielding abundant calcium require careful consideration of certain entities that include calcified fibrous pseudo tumor, calcified epidermal cyst, sarcoidosis, tuberculosis, lymphoepithelial lesion, pilomatricoma, osteitis fibrosa cystica, and extraskeletal osteosarcoma in the differential diagnosis.[7] A calcified fibrous pseudotumor shows abundant hyalinized collagen, fat, and neurovascular bundles along with calcification.[8] Calcified tuberculosis and sarcoidosis show a granulomatous reaction,[9]

whereas calcified epidermal cyst shows anucleate and nucleate squames. Pilomatricoma shows basaloid cells, ghost cells, and multinucleated giant cells in addition to calcification.[10] Lymphoepithelial lesions show a polymorphous population of lymphoid cells along with histiocytes and calcification.[7] Absence of any tumor cells rule out extraskeletal osteosarcoma. The clinical evaluation helps in the exclusion of osteitis fibrosa cystica. Reiter et al. reviewed various conditions that may lead to skin calcification and provided information regarding laboratory tests required to differentiate various types of calcinosis cutis.[1]

Shivkumar et al.[6] studied the cytological features of idiopathic scrotal calcinosis and noted the presence of intense, basophilic, amorphous, and granular deposits without any evidence of epithelial cells in the smears. In the present case, a negative history of trauma, hospitalization, parenteral therapy, underlying disease, or any preceding pathological lesion at the site, along with normal serum calcium and phosphorus levels clearly excluded the possibility of dystrophic, iatrogenic and metastatic causes and a final diagnosis of idiopathic calcinosis cutis was made.

Till date, there are very few case reports on FNA cytology of idiopathic calcinosis cutis in literature. Correct cytomorphological diagnosis goes a long way in determining cases requiring surgical rather than medical treatment.

To conclude, this case is highlighted to alert the pathologists to consider calcinosis cutis as a differential diagnosis in any swelling yielding whitish granular material on FNAC as it is a potential mimic of a neoplastic lesion. It also reaffirms that FNAC is a simple, rapid, and reliable technique especially in soft tissue lesions such as calcinosis cutis and in collaboration with serological and biochemical findings can help in effectively triaging the patient for the correct management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Reiter N, El-Shabrawi L, Leinweber B, Berghold A, Aberer E. Calcinosis cutis: Part I. Diagnostic pathway. J Am Acad Dermato 2011;65:1-14.  Back to cited text no. 1
    
2.
Datta C, Bandyopadhyay D, Bhattacharyya S, Ghosh S. Tumoral calcinosis. Indian J Dermatol Venereol Leprol 2005;71:293-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Valdatta L, Buoro M, Thione A, Mortarino C, Tuinder S, Fidanza C, et al. Idiopathic circumscripta calcinosis cutis of the knee. Dermatol Surg 2003;29:1222-4.  Back to cited text no. 3
    
4.
Sawke GK, Rai T, Sawke N. Iatrogenic calcinosis cutis: A rare cytological diagnosis. J Cytol 2016;33:166-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Muddegowda PH, Lingegowda JB, Ramachandrarao RK, Konapur PG. Calcinosis cutis: Report of 4 cases. J Lab Physicians 2011;3:125-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Shivkumar VB, Gangane N, Kishore S, Sharma S. Cytological features of idiopathic scrotalcalcinosis. ActaCytol 2003;47:110-1.  Back to cited text no. 6
    
7.
Choudhury M, Agarwal K, Singh S, Agarwal S. Cytodiagnosis of idiopathic calcinosis cutis: A Case report. Turk Patoloji Derg 2015;31:145-7.  Back to cited text no. 7
    
8.
Chorti A, Papavramidis TS, Michalopoulos A. Calcifying fibrous tumor: Review of 157 patients reported in international literature. Medicine (Baltimore) 2016;95:e3690.  Back to cited text no. 8
    
9.
Mortaz E, Masjedi MR, Matroodi S, Abedini A, Kiani A, Soroush D, et al. Concomitant patterns of tuberculosis and sarcoidosis. Tanaffos 2013;12:6-9.  Back to cited text no. 9
    
10.
Bansal C, Handa U, Mohan H. Fine needle aspiration cytology of pilomatrixoma. J Cytol 2011;28:1-6.  Back to cited text no. 10
[PUBMED]  [Full text]  

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Correspondence Address:
Anupama Arya
House No -77, Sector 15 A, Noida - 201 301, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_206_19

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