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A 54-year-old man developed a progressively enlarging painless mass on both forearms with limited range of flexion following 8 years of continuous ambulatory peritoneal dialysis (Figure 1, A.). Computed tomography showed amorphous, cystic, and multilobulated calcification at the medial aspect of his elbow joints, about 6 × 4 × 9 cm in size (Figure 1, B). His serum calcium, phosphate, and intact parathyroid hormone levels were 10.5 mg/dL, 6.0 mg/dL, and 1257 pg/mL, respectively. A sonogram disclosed evidence of 4 heterogeneous hypoechoic nodules ranging from 0.7 to 2.2 cm in the bilateral retrothyroid gland region. Conservative therapy with dietary phosphate restriction, noncalcemic phosphate binders, and vitamin D did not alleviate its progression. With a diagnosis of tertiary hyperparathyroidism with tumoral calcinosis, the patient underwent parathyroidectomy, and the calcified mass disappeared within 2 months (Figure 2).
Uremic tumoral calcinosis is an uncommon but serious complication of end-stage renal disease. It is characterized by massive extraosseous calcification in periarticular tissues, leading to limited range of joint movement, pain, and skin ulceration. Calcinosis has been reported to comprise calcium phosphate, hydroxyapatite, and a mixture of carbonate apatite and calcium carbonate.1 Surgical excision of the calcinosis lesion usually leads to unsatisfactory results because of local recurrence. Resolution of the calcinosis has been reported in cases receiving renal transplant and long-term daily nocturnal hemodialysis.2-3 Rapid regression of the calcified mass after parathyroidectomy in this case indicates that parathyroid hormone plays a pivotal role in disease progression. Parathyroidectomy may be a safe and promising therapy.