Calcification in the media of peripheral arteries is defined as Monckeberg’s medial sclerosis and can be seen in diabetic and elderly individuals. The calcium salt is usually deposited between muscle cells in the media. Although its etiology is still not known, its presence can predict the risk of cardiovascular events and leg amputation in diabetic patients. There have also been a few cases where healthy young men have had the medial calcification.

Generally, there are thought to be two different forms of arterial calcification: One is arterial intimal calcification, or atherosclerosis, and the other is medial calcification. Intimal calcification shows large and discontinuous calcific deposits in large and medium-sized arteries and a higher level of calcific deposit can lead to intraluminal stenosis or partial obstruction. However, medial calcification can be more finely grained and tends to involve the entire circumference or peripheral of small to medium-sized arterioles diffusely, so rather than obstruct the vascular lumen, it supports the structure.

Sanahan et al. said that Monckeberg’s medial sclerosis was caused by vascular smooth muscle cells (VSMC), which express many of the calcification regulating proteins commonly found in cartilage and bone. And several of those proteins are actually concentrated in vascular calcification. In cases where inhibitory proteins such as Matrix Gla protein, osteoprotegerin, Klotho, carbonic anhydrase and fibrillin I are lacking, VSMCs start to |row, proliferate and have an osteogenic phenotype ‘ ” Another study insisted that calcification is due to failure in clearing the resulting apoptotic fragments.
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When the lesion is located very superficially, such as on the face, pulsatile linea, arcuate, nodular or papular masses, bloody crusts, erosion or ulcers can clinically be observed. The typical feature of Monckeberg’s medial sclerosis by roentgenogram is a ring-like structure with a finely granular background. The affected artery, chain of rings, can sometimes be compared to a “goose neck” appear¬≠ance.

On histopathological analysis, Monckeberg’s medial sclerosis shows ring-like calcification within the media of vessels. Von Kossa staining can define the infiltration of calcium more clearly.

There is still no definite diagnostic criteria for Monckeberg’s medial sclerosis. Definite diagnosis mostly depends on histopathology. Plain x-ray and lab testing can be regarded as another evidence, but cannot actually give a definite diagnosis.¬†levitra professional

Medial calcification does not reduce arterial compliance, but is just a non-obstructive condition. Regardless of the cardiovascular risk factor, medial arterial sclerosis is a strong indicator of future cardiovascular occurences in diabetic patients. Medial arterial calcification is related to age and diabetes mellitus, especially in complicated and lon^-duration of diabetes mellitus. Psyrogiannis et al. found that microalbuminuria was strongly associated with medial arterial sclerosis, irrespective of the presence or absence of neuropathy.
Fig. 3. (A) Excised artery biopsy shows some continuous calcification on media of vessel in case 1 (H&E, X 100). (B) Von Kossa staining makes the calcification more definite gap (Von Kossa X 100).

Some studies also reported that the quantity of calcification is dependent on the not-controlled duration of the diabetes mellitus, not on the severity of diabetes mellitus.
In our cases, neither of the patients had diabetes mellitus. The only affected sites were found to be all the inferior labial arteries branching from the facial artery.

CONCLUSION

Herein, we report two rare cases of Monckeberg’s medial sclerosis in a 60-year-old man and 57-year- old woman, They both had asymptomatic, pulsatile, subcutaneous nodules on the cheek. Neither of them had diabetes meillitus, vascular calcification, or an abnormality in calcium metabolites. They were both diagnosed as Monckeberg’s medial sclerosis upon histopathologic examination. The cases have not yet been reported in the Korean dermatologic literature, and compared to other literature, it is thought that Monckeberg’s medial calcinosis can occur regardless of whether there is a presence of diabetes milletus.
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