A 63 y.o. male with a hx of a fall comes to the ED with pain in the distal long finger of the R hand.
What do you see?
Our patient had calcifications of the digital arteries and a history of peripheral vascular disease. Arterial calcification is associated with limb ischemia and he returned with a necrotic distal digit. Calcification is influenced by multiple factors including: loss of calcification inhibition activity, oxidized lipids, reactive oxygen molecules, cytokines, uremic toxins, high serum calcium and phosphate levels.
the patient returned with an ischemic finger
Calcification can be either amorphous which is the kind found in blood vessels or cause true ossification; with bone marrow and bony matrix. Calcification is generally found in three major situations.
INFLAMMATION- atherosclerosis causes calcification, infection (calcified abscess walls , tuberculosis), and trauma
calcified lymph nodes from tuberculosis
METABOLIC- chronic renal failure and diabetes are major causes of calcification
GENETIC FACTORS- gene deletions have been shown to cause calcification including pseudoxanthoma elasticum, hemochromatosis, Marfan’s and Wilson’s disease are examples.
Although the causes of calcification are multifactorial; the calcium and phosphorus levels are important and this led the use of the” calcium phosphorus product” in clinical medicine. Calcium is normally 8.5-10.5 and phosphorus is 2.5-4.5. The calcium phosphorus product is thought to be normal if it is less than 55.
calcification can occur in tumors because of a high calcium phosphorus product
The toxicity of phosphates in relation blood calcium has been known since 1917 when Binger discovered infusions of phosphate produced tetany in dogs. The calcium phosphorus product was first used by Howland in 1922 who showed that rickets was present in children when the calcium phosphorus product was less than 35. In contrast a high calcium phosphorus product is often found in calciphylaxis where phosphorus is high due to chronic renal failure and is deposited in the skin causing ischemia.
calciphylaxis
The calcium phosphorus product is not always predictive of calcium deposition. In some diseases like infantile arterial calcification, there is a lack of an enzyme that prevents calcium deposition with a normal calcium phosphorus product.
Our patient underwent an amputation of the distal digit.
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Howland J, Kramer B. Trans Am Soc Pediatr. 1922;34:2014-206.
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Ziegler S, Gahl W, Ferreira C. Disorders and Mechanisms of Ectopic calcification. Gnetics of bone biology and Skeletal disease(2nd ed) Academic Press 2018:571-595
Zettervall S, Marshall A, Fieser P Guzman R, Association of arterial calcification with chronic limb ischemia in patients with peripheral artery disease J Vasc Surg 2018 Feb;67(2):507-513.
Demer L, Tintuf Y. Inflammatory metabolic and genetic mechanism of vascular calcification. Arterioscler Thromb Vasc Biol 2014;23(4):715-23
arterial calcification in a child due to a lack of inhibition of hydroxyapatite formation. this is a genetic cause of calcification