Images in Clinical Medicine
Calcified Mass in a Patient on Long-Term Hemodialysis
N Engl J Med 1998; 338:1427May 14, 1998
- Article
Figure 1 A 46-year-old man with end-stage renal disease due to diabetic nephropathy had been undergoing hemodialysis for almost two years. Fourteen months after beginning dialysis, he reported pain below the right antecubital fossa, the site of an arteriovenous graft. A plain radiograph showed a nonpalpable calcification measuring 2 cm by 3 cm in the soft tissue. The patient had not been compliant in taking aluminum-containing phosphate binders and had been treated intermittently with intravenous calcitriol. His calcium–phosphate product (with both substances measured in milligrams per deciliter) ranged from 74 to 116 in the ensuing nine months (mean, 93). At the end of that time he presented with a several-day history of pain and swelling in the same antecubital fossa. A mass measuring 5 cm by 5 cm with mild overlying erythema that had not been present at previous dialysis sessions was palpable on the anterior surface of the forearm overlying the arteriovenous graft (Panel A). A plain radiograph (Panel B) and a computed tomographic scan (Panel C) revealed a large soft-tissue calcification in the antecubital fossa. Laboratory evaluation revealed the following values: serum calcium, 9.2 mg per deciliter (2.3 mmol per liter); phosphate, 8.5 mg per deciliter (2.7 mmol per liter); alkaline phosphatase, 60 U per liter; and intact parathyroid hormone, 185 pg per milliliter (normal, up to 54). Calcification presumably resulted from the presence of extravasated blood and soft-tissue injury caused by repeated venipuncture. During the following six months, the patient's compliance in taking aluminum-containing phosphate binders improved, and the mean calcium-phosphate product fell to 70. One year later the mass was smaller and the local pain and erythema had resolved, but computed tomographic scanning showed that the size of the calcification was unchanged. At no time was the function of the arteriovenous graft affected.
Piotr Lazowski, M.D.
David S. Goldfarb, M.D.
Veterans Affairs Medical Center, New York, NY 10010
