Calcinosis Cutis: A Rare Reaction to Subcutaneous Injections of Calcium-Containing Heparin in Patients With Renal Failure

Abstract

Calcinosis of the cutis and the subcutis is a rare complication of calcium-containing heparin cutaneous injections, mostly occurring in a context of severe renal failure. We report 2 cases. The first patient developed firm erythematous nodules on his thighs and right arm, in a context of disseminated tuberculosis and acute severe renal failure related to human immunodeficiency virus nephropathy. Cutaneous location of tuberculosis was suspected. Histological features allowed to establish the diagnosis of calcinosis of the cutis and the subcutis, showing violaceous and crackled von Kossa-positive calcium deposits in the whole reticular dermis and in thin collagenous septa of subcutaneous tissue. A retrospective inquiry confirmed that subcutaneous injections of calcium-containing heparin had been performed on the sites where lesions occurred. The second patient developed similar lesions at injection sites of calcium-containing heparin, in a context of non-Hodgkin lymphoma and end-stage renal failure. Similar histological features were observed. Calcinosis of the cutis and the subcutis after subcutaneous injections of calcium-containing heparin is rare. It always occurs in a context of elevated calcium-phosphate product, a situation mostly encountered in severe renal failure. Early cutaneous lesions do not bear specific clinical features.

Enoxaparin-Induced DRESS Syndrome

“…Anaphylaxis and angioedema are rare side effects of heparins [4]. Calcinosis cutis is also a rare reaction due to subcutaneous injections of calcium-containing heparin [1, 5]. …”

Cutaneous Deposits

“…Specifically, calcinosis cutis has been reported in fractures, burn scars, heel pricks in the neonatal period, keloids, venous ulcers, radiation sites, in a violin pressure point, 24 after calcium chloride or gluconate burns or infusions, 25 and the injection of calciumcontaining low-molecular-weight heparins in patients with chronic renal failure 26,27 (Fig. 4).…”

Les calcinoses cutanées

“…La panniculite calcifiante peut être déclenchée par des injections ou des traumatismes. Elle peut se compliquer d'infection ou de gangrène ; • les calcinoses cutanées secondaires aux injections sous-cutanées d'héparine contenant du calcium chez les insuffisants rénaux [3,34] : le tableau clinique et histologique est un peu différent de celui de la panniculite calcifiante. Cliniquement, les lésions sont des nodules érythémateux fermes aux zones d'injections d'héparine de bas poids moléculaire contenant des sels de calcium.…”