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Pathologic (Heterotopic) Calcification -

Abnormal calcium deposits.

Dr Sampurna Roy MD      

 

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Insoluble inorganic calcium salts are a normal constituent of bones and teeth.

      

 

Pathologic (Heterotopic) Calcification is the deposition of calcium salts in tissue other than osteoid and enamel.

The abnormal calcium deposits are present in injured and dead tissue.

The two main types are :

- Dystrophic Calcification:

- Metastatic Calcification:

Dystrophic Calcification:

In dystrophic calcification, serum calcium levels are normal and the calcium salts are deposited in dead or degenerate tissues.

This occurs in following sets of circumstances:

- Caseous calcification : Calcification is the key feature of old caseation. Example: Tuberculosis

    

- Fat necrosis : Traumatic fat necrosis seen in the breast.

Cystic degeneration may occur resulting in a cavity.

Calcification develops in the cyst wall. Fat necrosis in acute pancreatitis.

                   

- Thrombosis : Example: Calcified left ventricular thrombus, Coronary Artery Calcification, Calcified thrombus of the inferior vena cava in children, calcified superior vena cava thrombosis.

   

- Infarction : Example: Gamna-Gandy bodies in the spleen are nodular lesions containing fibrous tissue, haemosiderin and calcium. These are secondary to localized areas of haemorrhagic infarction.

       

- Haematoma. Example: Subdural haematoma or myositis ossificans.

       

- Atherosclerotic plaques.

- Chronic inflammation - Granulation tissue. Example: Constrictive pericarditis.

       

-   Monckeberg's sclerosis -   Monckeberg's sclerosis is a special form of arteriosclerosis characterized by calcification and ossification of the media of medium size arteries mainly of lower extremities.

      

- Infection - Schistosomiasis - Calcification of the ureters, bladder and seminal vesicles  may occur in genitourinary schistosomiasis.

          Visit: Pathology of Schistosomiasis

Diagnosis of congenital toxoplasmosis , an infection involving  the central nervous system, is suggested by the visualization of calcification in the infant brain.

 Visit: Pathology of Toxoplasmosis

- Degenerate colloid goitres

   

- Cysts of various types

- Calcinosis Cutis.  Visit: Pathology of Calcinosis Cutis

 

- Degenerate tumour. Example: Uterine leiomyoma

  

Metastatic Calcification:

In this condition the main defect is an elevated blood calcium level.

This may result from the removal of calcium from the bones.

Example: In hyperthyroidism or from excess calcium derived from the gut. In some cases high blood phosphate as in renal osteodystrophy.

This type of calcium deposition occurs in a variety of sites.

- The kidney - Deposition occurs round the tubules and damages them. Ultimately this may lead to renal failure.

      

These patients often show an inability to acidify their urine.

Stone formation in the renal pelvis and ureter is often associated with nephrocalcinosis.

   

- The lung - Calcium is deposited in the alveolar walls.

    courtesy:clipartlord.com

- The stomach. The calcium is deposited around fundic glands.

It has been suggested that since these glands secrete hydrochloric acid, the tissue are left relatively alkaline and this is said to favour calcium deposition.

 .

- Blood vessels     

- Cornea 

 

Causes of Metastatic Calcification:

There are five common causes of metastatic calcification:

1. Hyperparathyroidism, either as a result of primary or secondary hyperplasia, or as a result of neoplasia (parathyroid adenoma), the commonest type of parathyroid hyperactivity.

.

2. Excessive absorption of calcium from the bowel, which may be due to hypervitaminosis D or vitamin D sensitive states such as idiopathic hypercalcemia of infancy or even through excessive milk drinking.

3. Hypophosphatasia 

4. Destructive bone lesions

5. Renal tubular acidosis

3 to 5 are less common

Identification of Heterotopic Calcification:

On histological examination calcium salts appear as granules which stain a deep blue colour with haematoxylin.

They form encrustations on such structures as elastic fibres in the lung or in arteries.

Calcium salts can be stained with alizarin red S which stains them a magenta colour.

More commonly the von Kossa method is used, in which silver impregnation forms the basis of the stain.

What it shows is, in fact phosphate and carbonate, but since these are almost always associated with calcium when in its particulate and insoluble form, it constitutes quite an effective method fot the demonstration of calcium.

Other form of Pathologic Calcification:

Another form of pathologic calcification is the formation of stones containing calcium carbonate in sites such as the gallbladder, renal pelvis (discussed in metastatic calcification) , bladder, and pancreatic duct.

           

Stones in pancreatic duct         Stones in urinary bladder  

 

Stones in gallbladder                         

Under certain circumstances, the mineral salts precipitate from solution and crystallize around foci of organic material.

 

Summary of Dystrophic Calcification:

Dystrophic calcification occurs in nonviable or dying tissues in the presence of normal calcium serum level.

This is seen in arteries in atherosclerosis, in damaged heart valves and in areas of necrosis (coagulative, caseous and liquifactive).

Calcium can be intracellular, extracellular or in both locations.

Summary of Metastatic Calcification:

Metastatic calcification is the deposition of calcium salts in vital tissues and is always associated with hypercalcemia.

Calcium deposits are seen as amorphous basophilic densities that may occur widely throughout the body, affecting the interstitial tissues of blood vessels, kidneys, lungs and stomach.

 

Further reading:

Pericardial calcification in constrictive pericarditis.

Calcareous corneal degeneration: report of two cases.

Acquired immunodeficiency syndrome and ocular calcification.

Gastric mucosal calcinosis: clinicopathologic considerations.

Medial vascular calcification revisited: review and perspectives.

Primary hyperparathyroidism with metastatic pulmonary calcification: a case report and review of literature .

Metastatic pulmonary calcification in a patient with a functioning kidney allograft. Report of one case].

Metastatic pulmonary calcification: state-of-the-art review focused on imaging findings.

Coronary artery calcification in chronic kidney disease: An update.

Generalized arterial calcification of infancy: treatment with bisphosphonates.

Review article: Risks of coronary artery calcification in chronic kidney disease: do the same rules apply?

Hepatic artery calcification in a liver transplant recipient.

Mitral stenosis in tuberous sclerosis: a case of dystrophic calcification.

Idiopathic sclerochoroidal calcification.

 

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Dr  Sampurna Roy  MD

Consultant Histopathologist (Kolkata - India)

 

 


 

 

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