Tumoral calcinosis in a peritoneal dialysis patient

Abstract

A 39-year-old man with a history of end-stage renal disease secondary to IgA nephropathy had been on continuous ambulatory peritoneal dialysis for 4 years. He presented to the emergency department with a several-week history of left jaw pain. In addition he complained of right shoulder and right hand pain and swelling (Figures 1 and 2). Th e patient had not attended clinic for several months and had not adhered to dialysis nor oral medications as prescribed, including oral calcium and phosphate binders. A radiograph of the skull (Figure 3) demonstrates calcifi cation of the left submandibular gland. Radiographs of the right shoulder and hand (Figures 4 and 5) demonstrate articular and periarticular calcifi cations. Th e patient’s serum calcium was 2.18 mmol per liter (8.72 mg/dl), and the phosphate was 3.43 mmol per liter (10.6 mg/dl). Th e intact serum parathyroid hormone was measured to be 591 pg/ml (reference values 10–60 pg/ml). Th e patient was treated with oral phosphate binders and adhered to his dialysis prescription; over the following week his jaw pain resolved. Tumoral calcinosis in dialysis patients is typically multiple, is more common in males, and tends to occur in those with a longer duration of dialysis with uncontrolled calcium × phosphate products. Periarticular calcifi cations usually present with recurrent episodes of monarticular or oligoarticular arthritis. Treatment is directed at optimizing the calcium × phosphate product with the use of oral phosphate binders, ensuring dialysis adequacy, and, in some cases, parathyroidectomy or renal transplantation has preceded clinical improvement. Figure 1 | Photograph of the patient’s right shoulder, showing diffuse joint swelling.