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 metabolism[2]. 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 calcification[3,4].
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 calcification[5]. Calcified tuberculosis and sarcoidosis show a granulomatous reaction[6], whereas calcified epidermal cyst shows anucleate and nucleate squames. Pilomatricoma shows basaloid cells, ghost cells, multinucleated giant cells in addition to calcification[7]. Lymphoepithelial lesions show a polymorphous population of lymphoid cells along with histiocytes and calcification[8]. 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 cutis[2].
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 lithotripsy[9].
Till date, there are very few case reports on FNA cytology of idiopathic calcinosis cutis[10-12] 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 treatment.
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C, Dainese E. Idiopathic circumscripta calcinosis cutis of the
knee. Dermatol Surg. 2003;29:1222-4.
2) Reiter N, El-Shabrawi L, Leinweber B, Berghold A, Aberer E.
Calcinosis cutis: Part I. Diagnostic pathway. J Am Acad Dermatol.
2011;65:1-12; quiz 13-4.
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patient with systemic sclerosis. J Rheumatol. 1993;20:1233-5.
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of gamma- carboxyglutamic acid in the proteins associated
with ectopic calcification. Biochem Biophys Res Commun.
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5) Fetsch JF, Montgomery EA, Meis JM. Calcifying fibrous
pseudotumor. Am J Surg Pathol. 1993;17:502-8.
6) Pérez-Guillermo M, Sola Perez J, Espinosa Parra FJ. Asteroid
bodies and calcium oxalate crystals: Two infrequent findings in
fine-needle aspirates of parotid sarcoidosis. Diagn Cytopathol.
1992;8:248-52.
7) Unger P, Watson C, Phelps RG, Danque P, Bernard P. Fine needle
aspiration cytology of pilomatrixoma (calcifying epithelioma of
Malherbe): Report of a case. Acta Cytol. 1990;34:847-50.
8) Gunhan O, Celasun B, Dogan N, Onder T, Pabuscu Y, Finci
R. Fine needle aspiration cytologic findings in a benign
lymphoepithelial lesion with microcalcifications: A case report.
Acta Cytol. 1992;36:744-7.
9) Reiter N, El-Shabrawi L, Leinweber B, Berghold A, Aberer E.
Calcinosis cutis: Part II. Treatment options. J Am Acad Dermatol.
2011;65:15-22; quiz 23-4.
10) Das S, Kalyani R, Harendra Kumar ML. Cytodiagnosis of tumoral
calcinosis. Journal of Cytology. 2008;25:160-1.