54-year-old female patient presenting with progressive proximal muscle weakness affecting both legs. There was no history of trauma.
A 54-year old female patient with a known diagnosis of dermatomyositis presented with worsening proximal muscle weakness affecting both legs. Plain radiographs of the pelvis as well as both hips were obtained.
Extensive sheet-like calcifications were projected over the pelvis as well as along the soft tissues of both thighs. Additional radiographs of both knees were subsequently obtained to assess the full extent of these calcifications, which were found to extend to the soft tissues posterior to both knee joints.
A contrast enhanced CT was obtained from the level of L5 to the mid-femur for further assessment. The sheet-like calcifications were confirmed to be within the subcutaneous fat and fascial planes around the pelvis and upper inner thighs. Marked calcifications were also noted surrounding the right hamstring compartment without intra-muscular involvement.
Blood work drawn at the time of assessment revealed normal electrolytes including calcium and phosphate, CBC, and liver function tests. Creatine kinase, ESR and rheumatoid factor were also all within normal limits.
Dermatomyositis is a systemic connective tissue disease of unknown aetiology characterised by symmetric proximal muscle weakness accompanied by characteristic cutaneous manifestations. One of the cutaneous manifestations is calcinosis in the skin or muscles. It is found more commonly in juvenile dermatomyositis than in adults and may be present in 30-70% of cases [1].
Soft-tissue calcifications may be metastatic, dystrophic, idiopathic, or iatrogenic [1]. Calcinosis cutis is a deposition of insoluble calcium salts in the skin and is most commonly due to dystrophic causes in connective tissue diseases; hence, the calcium and phosphate metabolism is normal. The exact mechanism of calcium deposition is unclear but is presumed to be due to damaged, inflamed, or necrotic skin.
Imaging typically begins with plain radiographs but CT provides the advantage of determining the plane of calcification. The calcium deposits may be intracutaneous, subcutaneous, fascial, or intramuscular [2]. Compared to conventional radiography, CT is also more specific and sensitive in the detection of deeper soft-tissue calcifications [1]. MR images and whole-body scintigraphy with 99mTc medronate have been used to assess calcifications but it is not clear that they have improved detection over thin-slice CT.
Soft tissue calcinosis, particularly when florid, has been associated with pain, cosmetic disfigurement, and persistent ulceration with infection but most often is asymptomatic and found as an incidental finding on radiographic examination [2]. The natural history of calcinosis cutis is highly variable and unpredictable with cases ranging from spontaneous resolution to marked progression.
First-line therapy for localised disease begins with topical agents such as antipruritics and/or corticosteroids and systemic treatment courses for widespread disease [3]. For significant skin disease, antimalarials are usually used as first-line treatment, followed by other anti-inflammatory agents, systemic corticosteroids, corticosteroid-sparing immunosuppressants, biologics, and immunoglobulins.
54-year-old female patient with soft tissue calcinosis related to dermatomyositis.
Based on the provided pelvis and lower limb X-ray and CT images, there are cluster-like, patchy, or plaque-like high-density calcifications in the soft tissues around both hips and thighs. These widely distributed calcifications can be seen in the subcutaneous tissues and fascial compartments of the muscles. The overall bone structures appear basically normal, with no obvious signs of bone destruction or fractures. Some calcified areas are relatively dense and irregular in shape, indicating soft tissue calcium salt deposition. On CT cross-sectional views, multiple calcifications in the subcutaneous tissues and muscles are confirmed, without evident infiltration into the bone or destruction of bone structure.
Overall, these images primarily show widespread and prominent soft tissue calcifications, with a relatively clear relationship to the surrounding bone structures and no significant signs of bone damage.
The patient is a middle-aged female with clinically symmetrical proximal muscle weakness. The imaging findings of extensive soft tissue calcification closely align with dermatomyositis complicated by calcinosis, which is a typical presentation.
Conditions such as systemic scleroderma or mixed connective tissue disease may also present with similar soft tissue calcifications. However, given the known presentation of dermatomyositis in this patient, the first diagnosis is more likely.
This could occur due to hyperparathyroidism or renal failure leading to metastatic calcification, typically accompanied by abnormal calcium/phosphorus metabolism. However, the distribution here does not fully match those conditions, so the likelihood is relatively low.
Considering the patient is a 54-year-old female with progressive proximal muscle weakness and imaging findings of multiple soft tissue calcifications, without obvious metabolic abnormalities or bone lesions, the most consistent diagnosis is:
Dermatomyositis with Widespread Soft Tissue Calcinosis (Calcinosis Cutis)
Rehabilitation training should be gradual and tailored to the patient's condition and physical capacity. It is recommended to proceed under the guidance of a specialist in rehabilitation or physical therapy:
Throughout the rehabilitation process, the patient’s muscle strength, skin condition, and disease activity should be closely monitored. If any flare-ups or new symptoms appear, promptly consult with the specialist to adjust the treatment and rehabilitation plan accordingly.
Disclaimer: This report serves as a reference for medical analysis and does not replace in-person consultation or professional medical advice. The actual diagnosis and treatment should be determined by a qualified physician, based on a comprehensive assessment of clinical history, physical examination, and additional tests.
54-year-old female patient with soft tissue calcinosis related to dermatomyositis.
