Abdominal wall calcification in a peritoneal dialysis patient

Case report

Our patient had used combinations of dextrose peritoneal dialysis fluids, and icodextrin. Since June 2020, she was having two 5 L exchanges of 2.5% dextrose peritoneal dialysis fluid with an automated peritoneal dialysis machine at night, and icodextrin during the day. A peritoneal equilibration test revealed a high average transporter status. Her weekly Kt/V adequacy test was 1.7 (lower limit of normal). Her medication included amlodipine (10 mg od), telmisaratan (40 mg bd), calcitriol (0.25 μg od), and sevelamer (400 mg tds).

She presented with a feeling of tightness around her anterior abdomen. Examination revealed firm and pitting oedema of the anterior abdomen with no organomegaly. An abdominal radiograph revealed multiple subcutaneous calcific densities in the anterior abdominal wall, both gluteal regions, and the lateral aspects of both proximal thighs. Further, diffuse vascular calcifications in the aorta, coeliac trunk, splenic artery, common hepatic artery and its branches, both renal arteries and segmental branches, superior, inferior, and bilateral common iliac arteries and their branches (Fig. 1).

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Figure 1.

Abdominal computed tomography (CT): (a) plain study, axial view showing extensive calcification in the subcutaneous plane of the anterior abdominal wall; (b) coronal view showing extensive vascular calcification involving the aorta and its branches, the common iliac vessels, external and internal iliac artery; (c) coronal view showing subcutaneous calcification in the lateral abdominal wall and gluteal regions.

Laboratory investigations showed an anaemia (Hb 93 g/L), a leucocytosis (11.2 × 10⁹) and normal platelet count (4.45 × 10⁹); serum calcium: 2.62 mmol/L (previous values had risen from 2.2 → 2.3 → 2.35); phosphorus: 2.29 mmol/L; magnesium: 0.86 mmol/L; alkaline phosphatase: 2.56 μkat/L; parathomone: 140.7 pmol/L; vitamin D: 101 nmol/L. The anti-nuclear antigen, anti dsDNA, anti Sm antibody, anti–U1-RNP antibody and anti-centromere antibody tests were all negative. She had a normal serum pH: (7.32), bicarbonate: (19.6 mmol/L), pCO₂: (37.2 mm Hg), and pO₂: (94.5 mm Hg).

Tc-99m MIBI dual-phase parathyroid scintigraphy (Fig. 2) revealed evidence of an avidfocus in the right lobe inferior pole suggesting a parathyroid adenoma, thus providing a diagnosis of tertiary hyperparathyroidism (Fig. 2). Surgical removal of the adenoma was planned, but our patient sadly succumbed to coronavirus disease 2019 (COVID-19) disease beforehand.

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Figure 2.

Tc-99m MIBI dual phase parathyroid scintigraphy showing parathyroid adenoma.

Discussion

We found a report of a 39-year-old male who had haemodialysis for 6 years and had multiple nodules along his fingers and palms, which on radiography showed heavily calcified digital arteries with multiple nodular calcifications along the vessels. ¹ Further reports are of calcification of abdominal viscera in a patient on peritoneal dialysis suggested sclerosing, encapsulating peritonitis.^2,3

Calcinosis cutis, also known as benign nodular calcification, consists of calcium deposition within the cutaneous and subcutaneous tissues without tissue necrosis. Patients usually have firm white papules or plaques and nodules, commonly distributed in the periarticular areas and fingertips. A whitish discharge could be seen from these lesions. ⁴ It has five types: dystrophic, metastatic, idiopathic, iatrogenic and calciphylaxis. Dystrophic calcinosis cutis occurs in autoimmune conditions such as systemic sclerosis, dermatomyositis and systemic lupus erythematosus.

Metastatic calcification is a consequence of a high calcium phosphate level.

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