SUMMARYA 76-year-old man presented with abdominal pain and constipation for 1 month. The pain was dull aching in nature and over the right upper abdomen. He also reported decreased appetite. The patient had no previous attacks of acute pancreatitis or history of trauma. There was no history of fever or melena. On visual inspection of the abdomen, there was a mass effect protruding out of the right mid-abdomen. The mass was approximately measuring 15×15 cm, firm in consistency, non-tender, non-mobile and not moving with respiration. Haematological investigations were normal. Both amylase and lipase were within normal limits. A CT of the abdomen revealed a large welldefined thin-walled cystic lesion measuring 10.3×13.9×14.3 cm in the right lumbar and iliac region without calcification or haemorrhage. A diagnosis of retroperitoneal cyst was made and the patient was taken up for surgery. Histology of the cyst showed the absence of epithelia and was reported as pseudocyst. BACKGROUND

Idiopathic calcinosis cutis is a condition involving the deposition of calcium salts in the skin and subcutaneous tissue. The disease is a pathological condition of unknown origin and hence is idiopathic. The salt deposition is confined to areas such as the breast and vulva in females and scrotum and penis in males. Diffuse calcification with multiple complications in an adult is a rare entity. Only one such case has been reported in literature. A 59-year-old female presented to us with swelling of the right elbow, multiple calcific nodular lesions all over her fingers approximately 0.5x0.5 cm in size, and ulcers on her left great toe and right thumb with pain for the past two months. The ulcers were 2x2 cm and were observed to be healing without active discharge or signs of inflammation. The elbow was diffusely swollen and tender. Flexion deformity was present at the elbow. X-ray of hand and feet revealed calcinosis of the elbow and interphalangeal joints of the foot and hand. Blood tests revealed elevated C-reactive protein levels of 24 mg/dL, elevated Erythrocyte Sedimentation Rate (ESR) of 52 mm/hr., serum calcium of 9.7 mg/dL and a serum phosphorous of 5 mg/dL. Cultures from the foot ulcer were positive for methicillin-resistant staphylococcus aureus (MRSA). Workup for collagen vascular disease was negative. Histopathology confirmed calcinosis cutis. Treatment involved a conservative approach, including physiotherapy for the flexion deformity, antibiotics for MRSA, analgesics for pain relief and daily dressings. This case demonstrates that if a patient presents with multiple chalky nodular lesions with or without ulceration, pain and discharge involving areas of the upper limb or lower limb, diagnosis of idiopathic calcinosis cutis could be considered as a differential, despite its common confinement to the scrotum, breast, vulva and penis.

INTRODUCTIONTumors involving the parotid are predominantly primary with metastatic lesions forming a miniscule population. Meningioma metastasizing to the parotid is extremely rare and hence can often be mistaken for the more common primary salivary gland neoplasms.PRESENTATION OF CASEA 59-year-old male presented with a swelling in the left parotid region. Fine needle aspiration cytology was suggestive of myoepithelial predominant pleomorphic adenoma. A superficial parotidectomy performed revealed a tumor composed of rhabdoid cells with abundant finely granular eosinophilic cytoplasm raising a possibility of myoepithelioma. Immunohistochemistry for myoepithelial markers was negative. A critical review elicited a history of surgical excision of a recurrent rhabdoid meningioma twice. A possibility of metastasis was considered and a second panel of immunomarkers demonstrated vimentin and epithelial membrane antigen positivity. Neuroimaging studies demonstrated a space occupying lesion in the frontal lobe suggestive of a recurrent/residual tumor. In view of the history, neuroradiology, histopathology and immunohistochemistry, a final diagnosis of metastatic rhabdoid meningioma to the parotid was rendered.DISCUSSIONMorphologically, metastatic rhabdoid meningioma may mimic a primary or metastatic carcinoma, melanoma and sarcoma. Accurate diagnosis can be made by careful clinical evaluation and histopathological examination of the tumor. These tumors are composed of rhabdomyoblast like cells with abundant eosinophilic cytoplasm. The present case demonstrated characteristic histopathological features confirmed by immunohistochemistry.CONCLUSIONRhabdoid meningioma is an aggressive tumor with a high propensity to recur and metastasize. The present case highlights the importance of clinical, radiological and histopathological correlation to accurately diagnose these rare entities.