2015, Volume 31, Number 2, Page(s) 145-147
Cytodiagnosis of Idiopathic Calcinosis Cutis: A Case Report
Monisha CHOUDHURY, Kiran AGARWAL, Smita SÝNGH, Savita AGARWAL
Department of Pathology, Lady Hardinge Medical College, NEW DELHI, INDIA
Keywords: Calcinosis, Skin, Fine needle aspiration biopsy
We report a case of idiopathic calcinosis cutis diagnosed by fine
needle aspiration cytology in a 50-yr-old female who presented with a
subcu taneous swelling near the left iliac crest. Cytological finding of
amorphous calcium salts with histiocytes and the appropriate clinical
background led to the cytodiagnosis of idiopathic calcinosis cutis as
subsequently confirmed on histopathology. Pitfalls in the diagnosis of
calcinosis cutis on cytology smears are also discussed.
Calcinosis cutis develops due to deposition of
hydroxyapatite crystals of calcium phosphate in the skin.
There are various causes such as abnormal calcium or
phosphorus metabolism, tissue damage or idiopathic
factors. We present a case of idiopathic calcinosis cutis
diagnosed on fine needle aspiration (FNA) cytology in an
otherwise healthy woman. Points of caution for a correct
interpretation of the cytological findings are also discussed.
A female patient in her fifties presented with a solitary,
slowly growing lump close to left iliac crest for the last 7
years. There was no history of trauma or parenteral therapy
or family history of similar lesions. No history of pain or
discharge from the swelling was present. Clinically, there was
no evidence of any inherited or connective tissue disorder
and tests for anti nuclear antibodies and dsDNA were
negative. The patient had no other swelling or cutaneous
lesions such as blister or ulceration elsewhere in the body.
The nodule was located subcutaneously and measured
2.5x1.5 cm. It was hard to palpate with no connection with
the underlying bone. All biochemical and hematological
investigations including serum calcium and phosphorus
were within normal limits. Radiological survey showed
a calcified mass separate from adjacent bone. FNA of the
nodule was performed with a 22-gauge needle attached to a 10 ml syringe and yielded chalky white granular material.
Giemsa and Papanicolaou stains were used to stain the
smears. Microscopy showed amorphous granular material
staining bluish on Papanicolaou and dark grey on Giemsa
stain (Figure 1A
). A few histiocytes were also seen. The
smears were strongly positive with the Von-Kossa stain for
calcium (Figure 1B
). A cytodiagnosis of calcinosis cutis
was provided. The patient underwent surgical excision of
nodule followed by histopathological examination. The
gross specimen showed a hard, irregular lesion measuring
3x2 cm. On sectioning, the lesion was gritty with chalky
white calcified areas. Representative sections were taken
and stained with H&E and the Von-Kossa stain. Sections
showed nests of calcified material separated by fibrous septa
in the dermis without any significant inflammation (Figure
). The overlying epithelium was normal. Calcified material
was positive by the Von-Kossa stain, indicating a diagnosis
of calcinosis cutis.
Click Here to Zoom
|Figure 1: A) Calcific material with few histiocytes (Giemsa;
x400), B) Black calcified material (Von Kossa; x40).
Click Here to Zoom
|Figure 2: Histopathological section of resected mass showing
lobules of calcification separated by thick fibrous septa (H&E;
There is localized and organized deposition of calcium
in the skin in calcinosis cutis. Virchow first described
the disorder in 18551
. From the pathogenesis point of
view, the condition is classified as metastatic, dystrophic,
iatrogenic, idiopathic and calciphylaxis. Serum calcium and
phosphate levels remain normal in dystrophic calcification
whereas it is abnormal in metastatic calcification.
Calciphylaxis is associated with small vessel calcification
in the dermis and subcutaneous fat causing infarction
and there may be associated hyperparathyroidism and
disturbances in the phosphate and calcium metabolism2.
The idiopathic calcinosis term is used in the absence of any
identifiable cause of tissue calcification. In the present case,
a negative history of trauma and parenteral therapy 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.
The pathogenesis of calcification is unknown. However,
levels of gamma carboxyglutamic acid (GIa) have been
found to be elevated in calcified tissue as well as in the
urine of patients with calcinosis. It has been suggested that
de novo production of GIa can lead to ectopic soft tissue
FNA samples yielding abundant calcium require careful
consideration of certain entities that include calcified
fibrous pseudotumor, calcified epidermal cyst, sarcoidosis,
tuberculosis, lymphoepithelial lesion, pilomatricoma,
osteitis fibrosa cystica, and extra skeletal osteosarcoma in
the differential diagnosis. A calcified fibrous pseudotumor
shows abundant hyalinised collagen, fat, and neurovascular
bundles along with calcification5. Calcified tuberculosis
and sarcoidosis show a granulomatous reaction6, whereas
calcified epidermal cyst shows anucleate and nucleate
squames. Pilomatricoma shows basaloid cells, ghost cells,
multinucleated giant cells in addition to calcification7. Lymphoepithelial lesions show a polymorphous
population of lymphoid cells along with histiocytes and
calcification8. 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 cutis2.
The treatment for small calcified deposits and large localized
lesions is surgical excision which is curative and also
allows histopathological examination that is required for
confirmation of the diagnosis, whereas systemic therapy is
required for disseminated and extended calcinosis. Various
reported treatment modalities with beneficial effects include
warfarin, bisphosphonates, minocycline, ceftriaxone,
diltiazem, aluminum hydroxide, probenacid, intralesional
corticosteroids, intravenous immunoglobulins, curettage,
carbon dioxide laser, and extracorporeal shock wave
Till date, there are very few case reports on FNA cytology
of idiopathic calcinosis cutis10-12 which if properly
interpreted can lead to correct cytodiagnosis of this
disorder. The technique is of great diagnostic importance
in determining cases requiring medical rather than surgical
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