Uraemic tumoural calcinosis.

To cite: Al-ani M, Parperis K, Kelly CDB. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2016214773 DESCRIPTION A 22-year-old Hispanic woman, visiting from Mexico, with a medical history significant for endstage renal disease secondary to hypoplastic kidneys on peritoneal dialysis for the past 2 years and hypertension on nifidipine 30 mg daily, losartan 50 mg daily and prazosin 10 mg daily, presented with shortness of breath after missing peritoneal dialysis for 3 days, she was also reporting two large masses over her clavicles that were of indolent onset over the last year. Physical examination showed blood pressure of 191/130, heart rate of 77 bpm and normal temperature, there were crackles on bilateral lung bases and two subcutaneous nodular rubbery masses over the sternoclavicular joints (figure 1). Blood work showed haemoglobin 4.7 g/dL, blood urea nitrogen (BUN) 137 mg/dL; creatinine 20.87 mg/dL; calcium 10.4 mg/dL; phosphorus 9.7 mg/dL; alkaline phosphatase 240 IU; erythrocyte sedimentation rate 48 mm/L and parathormone intact was 2308.7 pg/mL, vitamin D level was 18 ng/mL, (Ca×P)=100.88 mg/dL (the Ca×P product should be maintained at level <55 mg/dL). Chest X-ray was significant for borderline cardiomegaly, prominent pulmonary vasculature, diffuse coarsely interstitial markings and dense calcifications at the sternoclavicular joints, bilaterally (figure 2). CT scan of the chest showed extensive overgrowth and calcinosis of the bilateral clavicular heads at the sternoclavicular articulation (figures 3 and 4). The patient was admitted and received 3 sessions of haemodialysis with low calcium dialysate over 4 days, she also received blood transfusions for her normocytic anaemia, and we started her on sevelamer carbonate 800 mg three times a day and cinacalcet 60 mg daily. On day 3, her laboratory results had improved with haemoglobin level 9 g/dL; BUN 85 mg/dL; creatinine 10.23 mg/dL; calcium 8.7 mg/dL; phosphorus 7 mg/dL (Ca×P)=60.9 mg/dL. On day 4, the patient started feeling better, we recommended further management with parathyroidectomy but she wanted to go back to her hometown to finish treatment. Tumoural calcinosis is an uncommon type of extraosseous periarticular calcification characterised by large rubbery or cystic masses containing calcium-phosphate deposits. It is more common in end-stage renal disease associated with tertiary hyperparathyroidism but it might occur as an Figure 1 Photograph of the two rubbery nodular masses over the sternoclavicular joints; skin is intact with no erythaema.