Hypercalcemia in children with malignancy is an uncommon condition. It has been described in leukemia patients with impaired renal excretion of calcium or osteolytic lesions. Metastatic calcinosis cutis (MCC) may develop if hypercalcemia persists. We report the case of a 5-year-old girl with an atypical dermatosis and unspecific gastrointestinal symptoms. Considered clinical diagnoses were xanthomas, histiocytosis, molluscum contagiosum, and nongenital warts. Cutaneous histological analysis showed amorphous basophilic deposits in the dermis suggestive of calcium deposits. Laboratory tests confirmed serum hypercalcemia. Extensive investigations such as bone marrow biopsy established the diagnosis of an acute pre-B cell lymphoblastic leukemia. Hypercalcemia in hematopoietic malignancies is unusual, especially as initial manifestation of the disease. Careful review of the literature fails to reveal previous reports of these peculiar cutaneous lesions of MCC in children with leukemia.
Hypercalcemia usually results in nonspecific constitutional and gastrointestinal symptoms, such as nausea, vomiting, anorexia, and weight loss. Its presence in children with malignancy is very rare but has been linked to rhabdomyosarcoma, hepatoblastoma, Hodgkin’s and non-Hodgkin’s lymphoma, brain tumors, neuroblastoma, angiosarcoma, and acute lymphoblastic and myeloid acute leukemia [
A 5-year-old girl with a history of nausea, vomiting, abdominal pain, and diarrhea, who had been hospitalized without a definite diagnosis of her illness on multiple occasions before her consultation, was admitted because of diarrhea and moderate dehydration.
Physical examination revealed asymptomatic large plaques of confluent papules, reddish brown on the groins, pubis, and gluteus fold, firm, and well demarcated, approximately 2 × 7 cm in size of four-week duration (Figures
Plaques of confluent papules, reddish brown on the groins, pubis, and gluteal fold, firm, and well demarcated.
Multiple pinkish, pearly, flesh colored papules.
Hematoxylin and eosin stain reveals amorphous, basophilic deposit in reticular dermis of calcium deposits; original magnification ×100.
Finally, a bone marrow biopsy revealed a significant hypercellularity with over 90% blasts with L1 morphology (Figure
Hematoxylin and eosin stain of bone marrow biopsy showed significant hypercellularity with over 90% blasts with L1 morphology; original magnification ×1000.
Immunohistochemical stain detected neoplastic cells positive for CD79a; original magnification ×1000.
Calcinosis cutis is classified as metastatic, dystrophic, idiopathic, or iatrogenic. Dystrophic calcinosis cutis is the most common form; it appears secondary to tissue damage in a setting of underlying disease associated with normal serum calcium and phosphate levels [
Hypercalcemia is defined as total serum calcium concentration greater than 12 mg/dL, but clinical symptoms usually appear when concentration is 15 mg/dL or greater [
MCC occurs when there is hypercalcemia or hyperphosphatemia secondary to abnormal calcium, phosphate metabolism, or both leading to spontaneous calcium/phosphate deposits [
In children with malignancy, hypercalcemia is uncommon. McKay and Furman reported that, over a period of 29 years, 25 out of 6,055 children treated for cancer were identified with hypercalcemia (0.4%) [
There is no specific treatment; intense hydration, biphosphonates, and corticosteroids to reduce calcium levels are usually indicated [
To the best of our knowledge, this case may represent the first pediatric patient with pre-B cell ALL and MCC, as no case with similar skin lesions has previously been informed in the literature. Its presentation highlights the importance of skin features in the diagnosis of a potentially severe hematologic disease. It was clear that an accelerated hypercalcemia in children with ALL can confuse the clinician due to nonspecific symptoms that may delay its diagnosis and treatment. Although cutaneous lesions represent a later sign of involvement, they are indistinguishable from other conditions such as xanthomas; thus, the histological analysis plays an important role for its recognition. In conclusion, although hypercalcemia with MCC is infrequent, it can be the initial manifestation of ALL.
All authors declare no conflict of interests.