A lump in the elbow—where did all that calcium come from?
Arielle Dumas, BS, Mamta Parikh, MD, Jeremy DeMartini, MD, Paul Aronowitz, MD, FACP
University of California, Davis Medical Center; Sacramento, CA
Introduction
Gross Pathology
•  Tumoral Calcinosis involves the deposition of calcium
within periarticular soft tissue forming lobular,
radiodense masses.
•  Patient was restarted on scheduled peritoneal dialysis.
•  Joint pain was initially treated with NSAIDs and
steroids, however, it persisted and radiographs were
obtained.
•  It is a rare, benign condition that is usually familial but
in some instances can result from metabolic
abnormalities.
•  The strict definition of tumoral calcinosis requires a
hereditary predisposition to the disease and normal
calcium levels. However, sporadic or idiopathic
occurrences of tumoral calcinosis have also been
reported.
•  On follow up questioning, the patient reported taking
high dose calcium acetate while he was in Mexico.
Gross images of left hand / right elbow showing nodular deformities at the metacarpal •  During hospitalization, calcium acetate was not
restarted and his calcium levels normalized.
joint and olecranon bursa
•  Patient was discharged after three weeks with outpatient
follow up.
Radiology
Take Home Points
•  We present a patient whose kidney failure combined
with excessive calcium intake led to tumoral calcinosis.
•  Tumoral calcinosis, although usually a benign
condition, can result in patient discomfort and
functional limitations.
Case Description •  A 62 year old man with a history of chronic kidney
disease stage 5, diabetes mellitus, gout and
hypertension, presented to the hospital after running out
of solution for his chronic peritoneal dialysis. He had
lost his insurance after an extended trip to his home
country of Mexico, and thus was hospitalized for
peritoneal dialysis. On review of systems he
complained of mild, chronic right knee pain.
Physical Exam
•  Secondary tumoral calcinosis has been associated with
a calcium phosphate product greater than 65-75 with
chronic kidney disease, where secondary
hyperparathyroidism often coexists.
•  Our patient had a calcium phosphate product of 89, but
did not have secondary hyperparathyroidism.
Radiographic imaging of right elbow mass showing lobular calcification
•  Firm, fixed, non-tender nodule on the right elbow
(diameter 2cm) and over the bilateral metacarpal joints.
There was mild tenderness over the right olecranon
bursa with extreme flexion and extension.
References
1. Eisenberg, B., et al., Periarticular tumoral calcinosis and
hypercalcemia in a hemodialysis patient without
hyperparathyroidism: a case report. J Nucl Med, 1990. 31(6): p.
1099-103.
Laboratory Results
2. Lykoudis, E.G., K. Seretis, and S. Ristanis, Huge recurrent tumoral
calcinosis needing extensive excision and reconstruction: report of
a rare case and brief literature review. Aesthetic Plast Surg, 2012.
36(5): p. 1194-7.
•  Calcium: 12.0 mg/dL
•  Phosphate: 7.4 mg/dL
•  PTHrP: negative
•  Treatment involves symptomatic management and
normalization of phosphate and calcium levels.
•  With normalization of calcium and phosphate, deposits
can gradually decrease in size.
•  Afebrile, normal vital signs, no apparent distress.
•  Vitamin D 16 ng/mL
Hospital Course
Right knee with extensive vascular calcifications
3. Olsen, K.M. and F.S. Chew, Tumoral calcinosis: pearls, polemics,
and alternative possibilities. Radiographics, 2006. 26(3): p. 871-85.