Calcific myonecrosis following snake bite: a case report and review of the literature

Abstract

IntroductionCalcific myonecrosis is a rare condition in which muscle in a limb compartment undergoes necrosis and becomes peripherally calcified with central liquefaction. The patient usually presents with a slowly progressive enlarged mass that sometimes can be misdiagnosed as soft tissue sarcoma. Most of the reported cases showed that the disease occurs often after trauma or compartment syndrome. However, the case of calcific myonecrosis following snake bite is rarely reported.Case presentationA 66-year-old Thai woman presented with a gradually progressive enlarged mass over a period of 10 years in her left leg. She had a history of untreated compartment syndrome after she was bitten by a snake (Malayan pit viper) in her left leg when she was 14-years old. At presentation, a plain X-ray showed a large soft tissue mass at the anterior compartment of her left leg. A sheet-like mass with an enlarged central cavity combined with peripheral calcification and cortical erosion of her tibia were observed. A biopsy was performed and the result was negative for neoplastic cells. During a 5-year follow-up, the mass progressively enlarged and then became infected and finally broke through the skin. She was treated by excision of the mass and administration of antibiotics. The wound completed healed at 1 month postsurgery. There was no wound complication or disease recurrence at 1 year postoperation.ConclusionsThe diagnosis of calcific myonecrosis was done by history taking and radiographic interpretation. In an asymptomatic patient the management should be observation and clinical follow-up. A biopsy should be avoided due to the high rate of postoperative infection. Treatment of choice in a symptomatic condition is mass excision.

Calcific myonecrosis following snakebite

“…If not fatal, puff adder bites frequently result in extensive necrosis that may require amputation of the affected limb. 20 A bite from one of these snakes is consistent with previous reports of compartment syndrome 7,13,14,21 and calcific myonecrosis 18,19 following viper bites. Interestingly, venom from the saw-scaled viper (which contains ecarin that activates prothrombin) has also been associated with renal cortical necrosis followed by calcification.…”

“…We report two similar cases of calcific myonecrosis of the anterior compartment of the lower leg that developed decades following snakebite. 18 The anterior compartment of the leg was affected and after a four-year period of conservative management, soft tissue breakdown necessitated surgical intervention in the form of mass resection and primary closure with vacuum drainage. Chun et al also reported a case of calcific myonecrosis following a snakebite.…”

Calcific Myonecrosis of the Leg: A Case Report

“…MRI is helpful to differentiate between the two. Another difference includes soft tissue neoplasm with secondary calcification [8] and dystrophic calcification in case of a hematoma, abscess or polymyositis [1,2,4]. In order to differentiate calcific myonecrosis from malignancy, a past history of a significant trauma and compartment syndrome play an important role; further, MRI is helpful to differentiate these two.…”

“…Previous case reports fail to discuss differentials and specific treatment guidelines [1,3,4]. In asymptomatic patients, the management should be observation and clinical follow-up [7,8]. Nonoperative treatment includes observation, analgesics if required and adequate care of the infection at any other area of the body.…”

“…Calcific myonecrosis is considered to be a late sequel of posttraumatic compartment syndrome [1]. Very few cases have been reported to date with confirmed diagnosis of calcific myonecrosis [1][2][3][4][5][6][7][8]. In this case report, we shall discuss the diagnostic approach, decision making, and surgical planning.…”