A 60 year old male presented with a painful lump over the right knee joint.
A 60 year old male presented with non traumatic painful lump over right knee associated with restriction of movement. There was no previous past history or family history of any renal or metabolic disorder. An X-ray of the knee showed a periarticular, dense, loculated, multi globular, homogenously calcified, soft tissue mass suggestive of Tumoral calcinosis.
Tumoral calcinosis also known as Lipocalcinogranulomatosis or Teutschlander’s disease, was first named by Inclan A et al in 1943. It is a clinicopathologic entity with characteristic radiological findings. The aetiology is incompletely understood though there is some evidence of autosomal dominant inheritance. Clinically the age of presentation is in first or second decade of life with an equal male to female ratio and an increased incidence in the afrocarribean population. The lesiona are usually periarticular (single or multiple joints) along the extensor surfaces. The joints involved most commonly are hips, elbows, shoulders, small joint of the feet and very rarely knees. It presents as a painful or painless swelling which can progress to cause limitation of joint movement; superficial skin ulceration and drainage of a chalky milk like material. Radiologically, presentation is of a dense, loculated, multiglobular, homogeneous mass of variable size with radiolucent septae giving a cobblestone or chicken wire appearance. Fluid-fluid levels may be seen with milk of calcium consistency which is known as sedimentation sign. The underlying bone is normal. Bone scan shows increased tracer uptake in soft tissues. Diagnosis should be considered in the presence of normal serum calcium level and once renal, metabolic, and collagen vascular disorders have been excluded. The management includes low phosphorus diet and phosphate binders such as aluminium hydroxide. When symptomatic, the mass can be surgically removed but there is high incidence of recurrence. The differential diagnosis includes disorders that cause calcium deposition in soft tissues, such as hyperparathyroidism, heterotropic ossification, dermatomysositis, metastatic calcification, hypervitaminosis D and gout.
Tumoral Calcinosis
Based on the provided X-ray and CT images, a sizable calcified mass is observed in the soft tissue near the right knee joint, appearing multi-septated or multi-cystic with relatively well-defined margins. The lesion shows high density, and certain areas exhibit septa or a “lattice-like” configuration, illustrating the typical “multi-cystic” or “curd-like” appearance. No obvious destruction or structural abnormality of the adjacent distal femur and proximal tibia is noted. Some views appear to reveal a fluid-fluid level, suggesting the presence of “milky calcium” deposits within the mass. Overall, these imaging characteristics are consistent with Tumoral Calcinosis.
Considering the typical multi-septated, curd-like or “chunky” calcifications on imaging, along with the lack of substantial bone involvement, these findings align with classic Tumoral Calcinosis. Clinically, patients may present with a periarticular mass, often accompanied by pain or restricted range of motion.
Certain metabolic conditions, such as secondary hyperparathyroidism or vitamin D overdose, can cause widespread soft tissue calcification. In these cases, laboratory tests frequently reveal notable abnormalities in serum calcium or phosphate levels.
On imaging, gouty tophi can manifest as dense soft tissue masses, but they typically involve bone erosion or show a “rat bite” sign. Clinically, gout most commonly affects the first metatarsophalangeal joint, and the morphology in this case differs from typical gout presentations.
In summary, based on the lesion’s location and imaging characteristics, and ruling out drastic metabolic abnormalities, Tumoral Calcinosis stands as the main diagnostic consideration.
Considering the patient’s profile—a 60-year-old male presenting with a painful mass around the right knee, imaging demonstrating a localized, multi-septated, heavily calcified soft tissue lesion with essentially normal adjacent bone—and excluding potential metabolic or secondary causes of calcification, the most fitting diagnosis is:
Tumoral Calcinosis
If further confirmation is needed, additional laboratory examinations (serum calcium, phosphate, parathyroid hormone levels, etc.) and corresponding pathological or clinical evaluations are recommended to rule out other metabolic disorders and inflammatory conditions.
1. Conservative Treatment: For patients with mild or no obvious symptoms, initial conservative management could include:
2. Surgical Treatment: In cases of severe pain, significant functional limitation, or upon risk of infection and skin compromise, surgical excision of the calcified lesion can be considered. However, recurrence is possible in this location, so postoperative metabolic control and follow-up are essential.
3. Rehabilitation and Exercise Prescription:
(1) Rehabilitation Goals: Alleviate pain, improve joint range of motion and muscle strength, and minimize the risk of recurrence.
(2) Early Phase:
4. Additional Considerations: In older patients or those with osteoporosis and cardiopulmonary comorbidities, remain vigilant about overexertion or safety risks. Exercises should be conducted under the supervision of qualified rehabilitation or medical professionals when necessary.
Disclaimer: This report is based on currently available information and serves only for reference. It should not replace in-person consultations or professional medical advice. If symptoms worsen or questions arise, seek immediate medical attention.
Tumoral Calcinosis
