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IMAGES IN RHEUMATOLOGY
Ahead of print publication  

Subcutaneous calcinosis as a harbinger of infection in a patient with relapsing dermatomyositis


1 Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission05-May-2021
Date of Acceptance17-May-2021

Correspondence Address:
Latika Gupta,
Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_87_21

  Abstract 


Keywords: Calcinosis, dermatomyositis, infection, subcutaneous



How to cite this URL:
Bhatia A, Prasad P, Thomas KN, Gupta L. Subcutaneous calcinosis as a harbinger of infection in a patient with relapsing dermatomyositis. Indian J Rheumatol [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=325440



A 37-year-old gentleman diagnosed with dermatomyositis (DM) 20 years ago returned to the outpatient clinic with erythema and anterior abdominal wall pain. He was previously diagnosed based on classic rashes of DM (heliotrope and Gottron's) in 2001, which recovered well with steroids. Despite being in clinical remission, he continued to have asymptomatic elevated muscle enzymes thereafter, until he had a relapse in 2019. His history is significant for a pleural effusion secondary to tuberculosis which was successfully treated and diabetes with nonalcoholic fatty liver disease, for which he is currently on oral hypoglycemics.

The current visit was attributed to an anterior abdominal wall subcutaneous abscess, which continued to drain for over 10 days, despite antibiotics and regular dressing. Notably, the patient did not have an inciting external wound or breach of the epithelium, which would have led to bacterial implantation in deeper tissue. The pus drained was chalky and contained amorphous white hard entities, leading to a suspicion of subcutaneous calcinosis. On staining and microscopic examination, the pus revealed deeply basophilic granular deposition on an inflammatory and necrotic background. A plain radiograph of the abdomen [Figure 1]e confirmed extensive calcinosis of soft tissue in the pelvis, along an irregular cavity, left lower limb, and to a lesser extent in the soft tissue of the lower limb as well, while clinically not communicating to the external surface. Tissue biopsy from the site of the infection confirmed necrotic granular material alongside irregular, basophilic calcium deposits [Figure 1]a and [Figure 1]b separating the skeletal muscle fibers [Figure 1]c and [Figure 1]d, further substantiating the possibility of subcutaneous calcinosis predisposing to de novo soft tissue infection devoid of external communication. Cultures indicated methicillin-resistant Staphylococcus aureus, for which vancomycin and azithromycin were initiated with uneventful recovery over 3 weeks.
Figure 1: (a and d) Section from abdominal tissue showing necrotic granular material along with irregular, basophilic calcium deposits separating the skeletal muscle fibers (H and E, ×100), which are stained black by von Kossa stain (von Kossa, ×100) highlighted with black arrows. (b) The von Kossa silver stain highlights the calcium salts (black) (Von kossa, ×400) highlighted with white arrows. (c) Cytological smear from pus showing crystalline calcium deposits lying amid dense inflammatory infiltrate (MGG stain, ×400) highlighted with black arrows. (e) Abdominal radiograph showing extensive calcinosis highlighted with white arrows

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Apart from diabetes and recalcitrant disease, subcutaneous calcification seems to be a risk factor for the soft tissue infection in this patient. Calcinosis in DM is characterized by dystrophic tissue calcification, oftentimes being surrogate for brewing inflammatory damage in the cutaneous and subcutaneous tissue, which may potentially be responsive to immunosuppressants. Although calcinosis is more frequent in juvenile DM (70%), approximately 20% of adults[1],[2] manifest with severe calcinosis. A high index of suspicion in the event of an atypical presentation of infection may be useful for early detection and timely management, with improved patient outcomes.

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.
Korlipara LV, Kiely P, Bodi I, Schon F. Neurological picture. Devastating calcinosis in a patient with adult onset myositis. J Neurol Neurosurg Psychiatry 2007;78:1005-6.  Back to cited text no. 1
    
2.
Orandi AB, Baszis KW, Dharnidharka VR, Huber AM, Hoeltzel MF; CARRA Juvenile Myositis subgroup. Assessment, classification and treatment of calcinosis as a complication of juvenile dermatomyositis: A survey of pediatric rheumatologists by the childhood arthritis and rheumatology research alliance (CARRA). Pediatr Rheumatol Online J 2017;15:71.  Back to cited text no. 2
    


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