Extensive scrotal calcinosis

Abstract

Case reportA 46-year-old man was referred to our clinic complainingof nodular lesions located on the scrotum that had graduallyenlarged over a period of 6 years. Due to poor psychosocialand cultural conditions, the patient did not seek medicaladvice until the nodules reached massive dimensions(Figs. 1 and 2). Physical examination revealed multiplenodules on the scrotal skin ranging between 1 to 3 cm indiameter. These were firm and mobile on palpation. Thenodules were only present on the scrotal skin. The patienthad no history of trauma, inflammatory disease or meta-bolic disorders. Urinalysis and blood chemistry tests werewithin normal limits. Subtotal excision of the scrotal wallwas performed. The skin was sutured with 3/0 absorbablesutures in horizontal mattress fashion. The histopathologi-cal examination revealed multiple calcified masses withinthe superficial and mid dermis. Epidermal cyst or eccrinecyst remnants were not observed within or around thelesions. The cosmetic results were excellent. No newlesions were observed during a 6-month follow-up (Fig. 3).DiscussionScrotal calcinosis (SC) was first described by Lewinski in1883 and more than 100 cases have been reported but itspathogenic mechanism is unclear. Clinically, there are hardyellowish nodules that vary in size: from 1 mm to severalcentimetres. Lesions can be solitary or multiple, locatedwithin scrotal skin and can share the characteristics ofepidermoid cysts. Although these nodules are usuallyasymptomatic, they can cause itching [1]. Disease occursusually in middle age and has a slowly growing pattern.Patients attend clinics primarily for aesthetic concerns andsuspicion of malignant disease [2].Whether SC is truly idiopathic or may be the result ofcalcification of preexisting cysts remains a controversialissue. Epidermal or eccrine cyst dystrophic calcificationswere generally accused but cases without any cysticcomponent have been reported. Ito et al. reported a caseof SC originating from eccrine epithelial cysts. This eccrineorigin was discovered via an immunohistochemical studyusing antibodies against carcinoembryonic antigen, epithe-lial membrane antigen and gross cystic disease fluidprotein-15 [3].Song et al. detected epidermal cysts with intact walls in apatient and established the following pathogenic mecha-nism. Cysts are formed, calcification of the intracystickeratinous content occurs with enlargement of the cyst anda subsequent attenuation of the wall. The structure of thecysts becomes indeterminate, along with rupture of theirwalls and the exposure of their contents. This triggers amononuclear cell inflammation or foreign body granulomawith resorption of the cyst walls and of the keratinousmaterial. Finally, only calcified deposits remain [4].Wright et al. conclude that the condition is trulyidiopathic, after failing to show positive staining with