A 26-year-old woman with no significant medical history underwent total thyroidectomy with central and left lateral neck dissection for newly diagnosed thyroid cancer. General anesthesia was administered, and all intraoperative medications were infused through a 20-gauge peripheral intravenous catheter placed at the dorsum of the right hand. Agents included propofol, lidocaine, remifentanil, fentanyl, rocuronium, cefuroxime, dexamethasone, acetaminophen, omeprazole, metoclopramide, magnesium sulfate, tranexamic acid, parecoxib, and ondansetron. The patient’s arms were tucked at her sides during the procedure.
Postoperatively, laboratory evaluation revealed hypocalcemia with serum calcium of 6 mg/dL (reference range 8.6–10.2) and parathyroid hormone less than 5 pg/mL (10–65). Two 1-g doses of 10% calcium gluconate were administered over 24 hours. During infusion, the patient developed pain, swelling, and erythema at the catheter site; these findings were attributed to local irritation and the infusion continued. After 18 hours, the catheter was removed and placed in her contralateral hand, and subsequent doses were given without incident. The patient remained afebrile and had no systemic symptoms, neurovascular deficits, or skin injury, and was discharged on postoperative day 2.
At the 10-day follow-up visit, the patient reported persistent swelling and pain in her right hand. As the edema resolved, discrete, tender white macules appeared on the dorsum of her hand within the areas where erythema had been observed during the infusion. She first noted the lesions around postoperative day 7. The patient was advised to apply aluminum paste and return for follow-up in 6 weeks.
At the 6-week visit, the lesions remained unchanged (Figure 1).
Dorsum of the right hand with discrete white macules within erythematous areas.
This presentation was most consistent with iatrogenic calcinosis cutis from calcium gluconate extravasation. Radiographs of the right hand at 6 weeks showed multiple stippled subcutaneous calcifications, most prominent near the ulnar styloid and fifth metacarpal, confirming the diagnosis (Figure 2).
Radiographs of the right hand showed stippled subcutaneous calcifications. The calcifications were most prominent near the ulnar styloid and fifth metacarpal (arrows).
CALCINOSIS CUTIS
The progression from acute infusion-site pain and erythema with persistent edema to delayed development of discrete, tender white macules, as seen in our patient, is characteristic of calcium salt deposition.1–4 Together, the calcium gluconate infusion, immediate infusion-site pain and swelling, delayed onset of tender white macules, and radiographic stippled calcifications make calcinosis cutis the diagnosis most consistent with the patient’s clinical course. Because these lesions often emerge days after infusion, patients may first present to outpatient clinicians, who must be aware of this delayed presentation to make an accurate diagnosis.
Systemic causes of metastatic calcification were excluded in our patient by laboratory evaluation showing no evidence of hypercalcemia or hyperphosphatemia at the time the lesions appeared. Calciphylaxis was also considered unlikely based on lesion morphology and clinical context; calciphylaxis typically presents with painful plaques that progress to ischemic necrosis and ulceration, most commonly involving the thighs, abdomen, or buttocks, features that were not observed in our patient. The differential diagnosis also included superficial thrombophlebitis, which typically presents with a tender, palpable cord and linear erythema, findings absent in this case. Cutaneous metastases from thyroid carcinoma are rare and most often involve the scalp, face, or neck in advanced disease; however, our patient had no evidence of disseminated disease, and the hand represents an atypical metastatic site.5 The absence of necrosis or neurovascular compromise further argued against a vascular etiology.
Management of calcinosis cutis includes immediate discontinuation of the infusion and limb elevation.1–4 Supportive measures include local cooling, tulle dressings, and topical or intralesional corticosteroids; topical or intralesional sodium thiosulfate has shown benefit in animal models.6,7
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2026 The Cleveland Clinic Foundation. All Rights Reserved.
References
- 1↵Pacheco Compaña FJ, Midón Míguez J, de Toro Santos FJ. Lesions associated with calcium gluconate extravasation: presentation of 5 clinical cases and analysis of cases published. Ann Plast Surg 2017; 79(5):444–449. doi:10.1097/SAP.0000000000001110
- 2Xu C, Turner A, Yeoh TM, Carney B. Management of severe calcium chloride extravasation injury: a case report. ANZ J Surg 2016; 86(5):421–422. doi:10.1111/ans.13437
- 3Girard P, Plancq MC, Tourneux P, Deroussen F, Gouron R, Klein C. Extravasation of calcium solution in the child: value of negative-pressure wound therapy. Arch Pediatr 2019; 26(7): 407–410. doi:10.1016/j.arcped.2019.09.011
- 4↵Rumancik BE, Rahnama-Moghadam S. Severe iatrogenic calcinosis cutis from extravasated calcium gluconate. Cureus 2020; 12(8):e9712. doi:10.7759/cureus.9712
- 5↵Sciscent BY, Eberly HW, Goyal N, Goldenberg D. Thyroid cancer with cutaneous metastases. Ear Nose Throat J. Published online March 14, 2024. doi:10.1177/01455613241239533
- 6↵Ahn SK, Kim KT, Lee SH, Hwang SM, Choi EH, Choi S. The efficacy of treatment with triamcinolone acetonide in calcinosis cutis following extravasation of calcium gluconate: a preliminary study. Pediatr Dermatol 1997; 14(2):103–109. doi:10.1111/j.1525-1470.1997.tb00214.x
- 7↵Pacheco Compaña FJ, Midón Míguez J, de Toro Santos FJ, et al. The use of antidotes for calcium gluconate extravasation: an experimental study in mice. Plast Reconstr Surg 2018; 142(3):699–707. doi:10.1097/PRS.0000000000004640
