Case Reports Calcinosis cutis: a report of four cases Angamuthu Natarajan MNAMS FRes' Anthony V Pais MS Res' Soransi R Chandrakala M0 2 Department of 'surgery and 2Pathology, St John's Medical College Hospital, Sarjapura Road, Bangalore-560034, Karnataka, India Correspondence to: Dr A Natarajan TROPICAL DOCTOR, 2003, 33, 50-52 Introduction Calcifying disorders of the skin and subcutaneous tissue is an uncommon metabolic disease referred to as calcinosis cutis'. Many terminologies are in vogue, the subtypes and their diagnosis is an issue of debate and confusion. Tumoral calcinosis is a rare form of calcinosis wherein deposition of calcified material occurs in the tissues near major joints, e.g. hip, elbow and shoulder joint 2 --4. This uncommon condition is predominantly reported in the African population and primary tumoral calcinosis accounts for 50% of the cases reported from tropics and sub-tropics l.3.5. The diagnosis is often missed clinically and it is important to rule out an underlying hyper- calcaemic condition in such cases. Surgical excision of the painful nodules or masses is recommendedS''. case history Case 1 An 85-year-old woman presented with history of a swelling over the left hip of 20 years duration. She noticed pain and an intermittent discharge of whitish turbid fluid from the swelling for 2 years. Examination of the left hip revealed an 8 x 6 em swelling in the upper and outer quadrant of the left gluteal region (Figure I). This hard, irregular, nodular swelling was close to the anterior superior iliac spine, fixed to the underlying muscles and the overlying skin. The skin over the swelling was hyperpigmented with a sinus on its summit, which exuded turbid greyish white fluid. Superolateral to this, a smaller second swelling measuring 3 x 2em was noticed, in the subcutaneous tissue and the overlying skin was free. A clinical diagnosis of actinomycosis or chronic tuberculous cold abscess was made. A roentgenogram of the left hip (Figure 2) showed a calcified soft tissue mass but no bony pathology of the hip joint was evident. Her serum calcium was 8.8 mg/dl, (N - 8.1-1O.4mg/dL) and phosphorous was 3.6mg/dL (N - 2.5-4.5 mg/dl.), The 24-hour urinary calcium level was 167mg (N - IQO-300 mg/24 h). The parathyroid hormone 50 Left iliac crest Tumour \ Region of left hip/gluteal region Fig. 1 Clinical photograph (first case) depicting the nodular swelling in the left gluteal region with a sinus on its summit Fig. 2 X-ray of the Jeft hip region (first case) showing the soft tissue calcification overlying the anterior superior iliacspine assay was normal, A thallium technetium subtraction scan revealed nonnal parathyroid glands. The larger swelling was excised and the resultant defect was covered with a split skin graft. The smaller swelling was excised. Histopathological examination confirmed the diagnosis of tumoral calcinosis (Figure 3). Case 2 A woman of 60 presented with swelling overlying the right gluteal region of I year's duration. There was no history of trauma but the swelling was painful. Two years previously, she had a similar swelling at the same site TropicalDoctor January 2003, 33