1
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Yousuf S, Busch D, Renner R, Schliep S, Erfurt-Berge C. Clinical characteristics and treatment modalities in uremic and non uremic calciphylaxis - a dermatological single-center experience. Ren Fail 2024; 46:2297566. [PMID: 38178572 PMCID: PMC10773653 DOI: 10.1080/0886022x.2023.2297566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024] Open
Abstract
Calciphylaxis (CP) is a serious, potentially life-threatening disease that presents with medial calcification of small-sized vessels and painful ischemic ulcerations. Although calciphylaxis is frequently seen in patients with end-stage kidney disease on dialysis (calcific uremic arteriolopathy, CUA), there are reported cases of nonuremic calciphylaxis (NUC), which often remain undiagnosed. We conducted a retrospective chart review at our dermatological hospital and evaluated data concerning the epidemiology, comorbidities, medication, laboratory abnormalities, and therapeutic approaches of 60 patients diagnosed with calciphylaxis between 01/2012 and 12/2022. We identified 21 patients diagnosed with NUC and 39 with kidney disease. The predilection sites of skin lesions were the lower legs in 88% (n = 53), followed by the thigh and gluteal regions in 7% (n = 4). Significant differences were identified in comorbidities, such as atrial fibrillation (p < 0.001) and hyperparathyroidism (p < 0.01) accounting for CUA patients. Medication with vitamin K antagonists (p < 0.001), phosphate binders (p < 0.001), and loop diuretics (p < 0.01) was found to be associated with the onset of calciphylaxis. Hyperphosphatemia (p < 0.001), increased parathyroid hormone (p < 0.01) and triglyceride levels (p < 0.01), hypoalbuminemia (p < 0.01) and decreased hemoglobin values (p < 0.001) in the CUA cohort were significantly different from those in the NUC group. All patients with CUA received systemic medication. In contrast, only 38% (n = 8) of patients with NUC received systemic treatment. Striking discrepancies in the treatment of both cohorts were detected. In particular, NUC remains a disease pattern that is still poorly understood and differs from CUA in several important parameters.
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Affiliation(s)
- Sabine Yousuf
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dorothee Busch
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Stefan Schliep
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Cornelia Erfurt-Berge
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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2
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Giese D, Ernste K, Jnaneswaran G, Elkhedr A. Non-chronic kidney disease-induced calciphylaxis: a rare case report. J Surg Case Rep 2024; 2024:rjae404. [PMID: 38835946 PMCID: PMC11149559 DOI: 10.1093/jscr/rjae404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/26/2024] [Indexed: 06/06/2024] Open
Abstract
Calciphylaxis is a disorder causing ischemic skin necrosis, typically associated with end-stage renal disease or those receiving dialysis. Occurrence is rare in those without end-stage renal disease, and treatment options are limited. This case report describes a patient with calciphylaxis without end-stage renal disease or history of dialysis. Treatment with sodium thiosulfate, a first line option, had to be stopped due to metabolic derangements, limiting the healing process. Diagnosis and treatment of this rare disorder are important to prevent further complications that may result.
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Affiliation(s)
- Drake Giese
- Medical College of Wisconsin - Central Wisconsin, Department of Education, 1900 Westwood Dr Suite 3100, Wausau, WI 54401, United States
| | - Katherine Ernste
- Medical College of Wisconsin - Central Wisconsin, Department of Education, 1900 Westwood Dr Suite 3100, Wausau, WI 54401, United States
| | - Geethu Jnaneswaran
- Marshfield Clinic, Division of Education - 1R61000 North Oak Avenue Marshfield, WI 54449, United States
| | - Ali Elkhedr
- Marshfield Clinic, Division of Education - 1R61000 North Oak Avenue Marshfield, WI 54449, United States
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3
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Grittani A, Kouzounis K, Zarry S, Suarez JH. The Accelerated Onset of Calciphylaxis in a 72-Year-Old Female Hemodialysis Patient. Cureus 2024; 16:e58492. [PMID: 38765385 PMCID: PMC11101609 DOI: 10.7759/cureus.58492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Calciphylaxis is a unique medical condition characterized by calcification of the medial layer of arterioles and soft tissues in a patient's skin at the level of the dermis and subcutaneous adipose tissue. The rate of progression of calciphylaxis is rapid, starting with a reduction of blood flow that leads to ischemic changes in the skin that can manifest as painful cutaneous erythematous nodules or plaques and later as skin ulceration. The majority of patients affected by calciphylaxis have predisposing comorbidities such as end-stage renal disease with a long history of hemodialysis and electrolyte abnormalities in calcium, phosphate, and parathyroid hormone levels. This report presents the case of a 72-year-old female patient on hemodialysis who developed calciphylaxis. The methods for early prognosis (the methods of early diagnosis), including clinical presentation, risk factors, imaging techniques, and laboratory investigations, are discussed. The presented case is particularly noteworthy given the onset of calciphylaxis within a mere three months of initiating hemodialysis, a timeline significantly shorter than the typically observed period in most patients. (The case detailed in this report outlines the rapid onset of calciphylaxis in a patient who was receiving hemodialysis for only three months.) This patient with early-onset calciphylaxis highlights the unpredictable nature of calciphylaxis and the need for increased clinical vigilance even in the initial stages of hemodialysis.
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Affiliation(s)
| | | | - Samantha Zarry
- Internal Medicine, The University of Western Ontario, Toronto, CAN
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4
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Bukhari S, Ghoweba M, Bartholomew JR, Hornacek D. Images in Vascular Medicine: Nonuremic calciphylaxis secondary to occult malignancy. Vasc Med 2024; 29:225-226. [PMID: 38102937 DOI: 10.1177/1358863x231215327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Syed Bukhari
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamed Ghoweba
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - John R Bartholomew
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Deborah Hornacek
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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5
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Toussaint ND, Davies CE, Bongetti E, Ruderman I, Elder GJ, Hawley CM, Krishnasamy R, Roberts MA, Jardine MJ, De Zoysa JR, McDonald SP. Calciphylaxis Episodes in the Australia and New Zealand Dialysis and Transplant Registry. Kidney Int Rep 2024; 9:951-959. [PMID: 38765561 PMCID: PMC11101771 DOI: 10.1016/j.ekir.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/06/2024] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Calciphylaxis is a rare disorder associated with significant morbidity and mortality. Data registries are an invaluable source of information for rare diseases. We reviewed cases of calciphylaxis recorded in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and evaluated associations and outcomes of this condition. Methods Data was obtained on all cases of calciphylaxis reported between 2019 and 2022 in Australian and New Zealand patients on kidney replacement therapy (KRT). This cohort was compared to all patients in the registry who received KRT from 2019 to 2022 without an episode of calciphylaxis. Cox proportional hazards regression including a time-varying covariate for calciphylaxis episode was conducted for mortality with models restricted to patients on dialysis only. Results From 2019 to 2022, 333 patients had calciphylaxis episodes reported. Overall incidence rate for patients on dialysis was 4.5 (4.1-5.1) episodes per 1000 patient-years on dialysis. Median age was 63 (interquartile range [IQR]: 55-73) years, 54% were female, 66% had diabetes, 59% were obese (body mass index [BMI] ≥ 30 kg/m2) and 77% were receiving hemodialysis (HD) treatment. Compared to patients without calciphylaxis (n = 46,526), patients with calciphylaxis were more likely to be older, female, and have diabetes, greater BMI, coronary artery, and peripheral vascular disease. The median time to calciphylaxis was 3.2 (IQR: 0.9-6.7) years after KRT commencement. Half of the patients with calciphylaxis died by 12 months from diagnosis. Adjusted hazard ratio (HR) of mortality for patients on dialysis with calciphylaxis <1 year and 1 to 4 years after an episode was 5.8 (4.9-6.9) and 1.5 (1.0-2.1), respectively compared to patients on dialysis without calciphylaxis. Conclusion Calciphylaxis is a rare but life-threatening condition in people on KRT with the greatest mortality burden within 12 months of diagnosis.
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Affiliation(s)
- Nigel D. Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Christopher E. Davies
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Elisa Bongetti
- Department of Nephrology, Monash Medical Centre, Clayton, Australia
| | - Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Grahame J. Elder
- School of Medicine, University of Notre Dame, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Skeletal Biology Program, Garvan Institute of Medical Research, Darlinghurst, Australia
- Department of Nephrology, Westmead Hospital, Sydney, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast Hospital University Hospital, Birtinya, Australia
| | | | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney New South Wales, Australia
- Department of Nephrology, Concord Repatriation General Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW, Sydney Australia
| | - Janak R. De Zoysa
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Waitemata, Auckland, New Zealand
| | - Stephen P. McDonald
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, Australia
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Xia J, Tan AJ, Gabel CK, Nguyen ED, Chand S, Rrapi R, Dobry AS, Garza-Mayers AC, Ko LN, Shah R, St John J, Nigwekar SU, Kroshinsky D. Prevalence and risk factors for development of recurrent calciphylaxis. J Am Acad Dermatol 2024:S0190-9622(24)00380-3. [PMID: 38382710 DOI: 10.1016/j.jaad.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Joyce Xia
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alice J Tan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Colleen K Gabel
- Department of Dermatology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Emily D Nguyen
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sidharth Chand
- Department of Dermatology, University of California Irvine Health, Irvine, California
| | - Renajd Rrapi
- Department of Dermatology, New York University Langone Health, New York, New York
| | - Allison S Dobry
- Department of Dermatology, University of California San Francisco Health, San Francisco, California
| | - Anna Cristina Garza-Mayers
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Lauren N Ko
- Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica St John
- Department of Dermatology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Sagar U Nigwekar
- Harvard Medical School, Boston, Massachusetts; Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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7
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Hofmann AG, Deinsberger J, Oszwald A, Weber B. The Histopathology of Leg Ulcers. Dermatopathology (Basel) 2024; 11:62-78. [PMID: 38390849 PMCID: PMC10885126 DOI: 10.3390/dermatopathology11010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.
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Affiliation(s)
- Amun Georg Hofmann
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - André Oszwald
- Department of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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8
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Yu Y, Chen Y, Yang F, Song Q. Black necrosis of the glans penis associated with calciphylaxis: A case report. Medicine (Baltimore) 2023; 102:e35609. [PMID: 37861559 PMCID: PMC10589551 DOI: 10.1097/md.0000000000035609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
RATIONALE Calciphylaxis, known as calcific uremic arteriolopathy, is a rare cause of dry gangrene. Despite an increase in the clinical recognition of demographic characteristics and risk factors associated with calciphylaxis, it remains a poorly understood disease with high mortality. PATIENT CONCERNS AND DIAGNOSES We present a 45-year-old man, who was diagnosed with calciphylaxis disease, with a history of diabetes mellitus, end-stage renal disease and cirrhosis with a half-month evolution of painful dry gangrene on his glans penis and scrotum. The patient also presented with gangrene of fingers. INTERVENTIONS AND OUTCOMES The patient and his family opted for palliative care. However, he died eventually. LESSONS This case contributed to the current understanding of calciphylaxis. Since no standard treatment is available and the prognosis remained poor, early, and accurate diagnosis of calciphylaxis is important. We here report the current case and provide data for the diagnosis and treatment of this kind of disease.
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Affiliation(s)
- Youwei Yu
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yangxi Chen
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Fan Yang
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Qitai Song
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
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9
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Khalayli N, Hodifa Y, Hodaifa A, Alsamarrai O, Kudsi M. Calciphylaxis during the course of psoriatic arthritis patient. Is it coincidence? A case report. Ann Med Surg (Lond) 2023; 85:5263-5266. [PMID: 37811033 PMCID: PMC10552990 DOI: 10.1097/ms9.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/27/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and importance Calciphylaxis manifests clinically by skin ischemia and necrosis and histologically by calcification of dermal arterioles. Usually, it occurs in patients with end-stage renal disease on dialysis or in patients who had a kidney transplant. Here, the authors present a case of calciphylaxis occurring in a patient with psoriasis and psoriatic arthritis. Case presentation A 66-year-old Syrian male with a history of psoriatic arthritis presented for evaluation of 2-month nonpainful ulcers on his feet and hands that were treated with warfarin. Biopsies confirmed the diagnosis of calciphylaxis. The patient received sodium thiosulfate, zoledronic acid, intralesional sodium thiosulfate injections, and an intravenous infusion of vitamin K with dramatic improvement. At the 3-month follow-up, his wounds had been completely remitted. Discussion Nonuremic calciphylaxis occurs in many cases, like vitamin D administration, vitamin K antagonists' administration, chronic inflammation, and others. The association between calciphylaxis and psoriasis was reported only in four cases in the literature; meanwhile, this was the first case that described calciphylaxis in the setting of psoriatic arthritis. Conclusion A suspicion of calciphylaxis should be maintained in patients with underlying inflammatory mechanism diseases.
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Affiliation(s)
| | - Yara Hodifa
- Faculty of Medicine, Damascus University, Damascus, Syria
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10
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Costa E Silva J, Ramos JN. Calciphylaxis Secondary to Vitamin D Supplementation. Cureus 2023; 15:e44778. [PMID: 37809218 PMCID: PMC10556987 DOI: 10.7759/cureus.44778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Calciphylaxis is a rare cutaneous disease consisting of purpuric and necrotic lesions, and it affects mostly patients with renal failure. More rarely, it can be observed in patients with preserved renal function, acquiring the name of non-uremic calciphylaxis (NUC). Although its pathophysiology is under uncertainty, many etiological factors have been implicated. This report describes a patient who developed NUC, possibly triggered by vitamin D supplementation.
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Affiliation(s)
- Joana Costa E Silva
- Plastic Reconstructive and Maxilofacial Surgery, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - José N Ramos
- Plastic Reconstructive and Maxilofacial Surgery, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
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11
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Al Yacoub R, Jamalifard F, Ladna M, Walker A. Non-uremic Calciphylaxis With Possible Initial Misdiagnosis as Erythema Multiforme/Toxic Epidermal Necrolysis Successfully Treated as Inpatient. Cureus 2023; 15:e43618. [PMID: 37719563 PMCID: PMC10504681 DOI: 10.7759/cureus.43618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Non-uremic calciphylaxis (NUC) is a rare, high-mortality disease, and it can be easily misdiagnosed as other ulcerative dermatologic conditions. A female in her late 30s with a medical history of alcoholic liver cirrhosis and obesity who previously underwent gastric bypass surgery presented with an 11-month history of worsening bilateral lower extremity wounds following the initiation of spironolactone. A wound biopsy at the time of initial presentation favored erythema multiforme/toxic epidermal necrolysis (EM/TEN). She initially responded to systemic steroids, but her wounds later worsened, prompting her to seek representation a few months later. The initial suspicion was for a superimposed bacterial infection; however, her wounds did not improve following antibiotics. A repeat skin biopsy revealed calciphylaxis, for which she had multiple risk factors, including severe vitamin D deficiency causing secondary hyperparathyroidism. A multidisciplinary approach was successful in achieving a satisfactory response with pain control, wound care, skin grafting, and mitigation of risk factors in addition to the use of sodium thiosulfate. Upon our review, the initial biopsy did not demonstrate features of EM/TEN but did demonstrate features suspicious for calciphylaxis. The exposure to systemic corticosteroids due to the presumed diagnosis of EM/TEN may have worsened her condition since this is a known risk factor for calciphylaxis. Our case highlights the importance of clinicopathologic correlation as well as the place for calciphylaxis in the clinical and histopathologic differential diagnosis of ulcerated, necrotic lesions on the lower extremities in the absence of renal disease.
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Affiliation(s)
- Raed Al Yacoub
- Internal Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Faread Jamalifard
- Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Michael Ladna
- Internal Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Addie Walker
- Dermatopathology, University of Florida College of Medicine, Gainesville, USA
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12
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Lum K, Gardner J, Dao H. A case of nonuremic calciphylaxis of the penis responding to sodium thiosulfate therapy. JAAD Case Rep 2023; 38:4-7. [PMID: 37456516 PMCID: PMC10338229 DOI: 10.1016/j.jdcr.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Affiliation(s)
- Kalisa Lum
- Loma Linda University School of Medicine, Loma Linda, California
| | - Jeffrey Gardner
- Department of Dermatology, Loma Linda University, California
| | - Harry Dao
- Department of Dermatology, Loma Linda University, California
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13
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Gleue C, Bois M, Guo R. Calciphylaxis in autopsy: A retrospective case-controlled study of 7 decedents. JAAD Case Rep 2023; 35:60-62. [PMID: 37078015 PMCID: PMC10106467 DOI: 10.1016/j.jdcr.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Affiliation(s)
- Casey Gleue
- Division of Anatomic and Clinical Pathology, Mayo Clinic, Rochester, Minnesota
| | - Melanie Bois
- Division of Anatomic and Clinical Pathology, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ruifeng Guo
- Division of Anatomic and Clinical Pathology, Mayo Clinic, Rochester, Minnesota
- Correspondence to: Ruifeng Guo, MD, PhD, Hilton Building, Mayo Clinic Department of Anatomic and Clinical Pathology, 210 2nd St SW, Rochester, MN 55905.
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14
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Martí Pelluch CC, Soler Sendra A, Vila Vall-Llovera M. Non-uremic calciphylaxis: case series. Med Clin (Barc) 2023; 160:318-319. [PMID: 36473774 DOI: 10.1016/j.medcli.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/05/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Affiliation(s)
| | - Anna Soler Sendra
- Servicio de Medicina Interna, Hospital General de Granollers, Granollers, Barcelona, España
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15
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Ficenec S, Gerstein B, Shamburger CD. Calcific uraemic arteriolopathy presenting as cellulitis of the dorsal foot. BMJ Case Rep 2023; 16:e251758. [PMID: 37015767 PMCID: PMC10083774 DOI: 10.1136/bcr-2022-251758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
Calcific uraemic arteriolopathy (CUA) is a rare and poorly understood entity that typically presents with painful lesions affecting adipose-rich areas of the lower extremities. We report an unusual case of CUA presenting as presumed cellulitis of the dorsal surface of the distal lower extremity with acute development of a bullous lesion. As CUA incidence is predicted to increase due to its relationship with end-stage renal disease, recognising the full clinical spectrum of this disease is essential to promote further understanding of this disorder and exploration of additional therapeutics to limit disease morbidity and mortality.
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Affiliation(s)
- Samuel Ficenec
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Brittany Gerstein
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
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16
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Penile Focal Erythematous Macules and Patches: Answer. Am J Dermatopathol 2023; 45:273-274. [PMID: 36921304 DOI: 10.1097/dad.0000000000002376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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17
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Roberson JL, Butt Z, Florez-Pollack S, Morgan E, Rosenbach M, Braslow BM, Yelon JA. An Intensive Multidisciplinary Approach in Management of Extensive Nonuremic Calciphylaxis of the Bilateral Lower Extremities with Angioinvasive Fungus and Mold. J Burn Care Res 2023; 44:218-221. [PMID: 36269818 DOI: 10.1093/jbcr/irac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Indexed: 01/11/2023]
Abstract
Management of infected wounds related to calciphylaxis poses a significant clinical challenge with high morbidity and mortality. Given no definitive management guidelines exist specific to nonuremic calciphylaxis, multiple modalities including sodium thiosulfate, antibiotics, hyperbaric oxygen therapy, and surgical debridement with wound care must be considered. When occurring over a large surface area, standard daily dressing changes are especially labor intensive, inefficient, and ineffective. Negative pressure wound therapy with instillation and dwell time offers broad wound coverage with ongoing therapeutic benefit. We present the case of a previously healthy 19-year-old woman who was transferred for tertiary level care of extensive nonuremic calciphylaxis wounds of the bilateral lower extremities complicated by angioinvasive coinfection with fungus and mold that was managed with a multidisciplinary approach of intensive medical management, aggressive surgical debridement, and negative pressure wound therapy with instillation of hypochlorous acid solution. Ultimately, she achieved full granulation and wound coverage with skin grafting. Large area, infected wounds related to nonuremic calciphylaxis can be successfully managed with multidisciplinary medical management, aggressive surgical debridement, and negative pressure wound therapy that can instill and dwell hypochlorous acid solution.
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Affiliation(s)
- Jeffrey L Roberson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zoya Butt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Florez-Pollack
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Morgan
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Misha Rosenbach
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin M Braslow
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jay A Yelon
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gholizadeh Ghozloujeh Z, Rajasekaran A, Abdipour A, Norouzi S. Calciphylaxis in a Patient With Lupus Nephritis and Acute Kidney Injury: A Rare Case Report and Literature Review. J Investig Med High Impact Case Rep 2023; 11:23247096231215705. [PMID: 38097351 PMCID: PMC10725146 DOI: 10.1177/23247096231215705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 12/18/2023] Open
Abstract
Calciphylaxis is a rare and severe disease characterized by calcification, fibrosis, and thrombosis of small blood vessels. Although it primarily affects patients with end-stage renal disease (ESRD) on dialysis, limited cases have been reported of calciphylaxis in patients with acute kidney injury (AKI) and lupus. This case report describes the occurrence of calciphylaxis in a 35-year-old female recently diagnosed with lupus nephritis class IV and AKI requiring dialysis.
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Tamagake M, Nagao M, Miura C, Imai Y. Surgical treatment of nonuremic calciphylaxis: a case report and review of literature. Case Reports Plast Surg Hand Surg 2022; 10:1-6. [PMID: 38229696 PMCID: PMC10790797 DOI: 10.1080/23320885.2022.2145962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 11/04/2022] [Indexed: 12/23/2022]
Abstract
Calciphylaxis is characterized by extremely painful skin ulcers and develops in patients with or without severe kidney diseases. Herein, a female patient without renal dysfunction developed calciphylaxis in the right lower extremity and underwent successful surgical debridement and split-thickness skin grafting. Nevertheless, prompt wound evaluation and proper surgical approaches are essential.
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Affiliation(s)
- Minami Tamagake
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Munetomo Nagao
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Chieko Miura
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Yoshimichi Imai
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
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20
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Rowe PS, McCarthy EM, Yu AL, Stubbs JR. Correction of Vascular Calcification and Hyperphosphatemia in CKD Rats Treated with ASARM Peptide. KIDNEY360 2022; 3:1683-1698. [PMID: 36514737 PMCID: PMC9717652 DOI: 10.34067/kid.0002782022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/25/2022] [Indexed: 01/11/2023]
Abstract
Background Abnormalities in calcium, phosphorus, PTH, vitamin D metabolism, bone, and vascular calcification occur in chronic kidney disease mineral bone disorder (CKD-MBD). Calciphylaxis, involving painful, ulcerative skin lesions, is also a major problem associated with CKD-MBD. There are no quality medical interventions to address these clinical issues. Bone ASARM peptides are strong inhibitors of mineralization and induce hypophosphatemia by inhibiting phosphate uptake from the gut. We hypothesize treatment of CKD-MBD rats with ASARM peptides will reverse hyperphosphatemia, reduce soft-tissue calcification, and prevent calciphylaxis. Methods To test our hypothesis, we assessed the effects of synthetic ASARM peptide in rats that had undergone a subtotal 5/6th nephrectomy (56NEPHREX), a rodent model of CKD-MBD. All rats were fed a high phosphate diet (2% Pi) to worsen mineral metabolism defects. Changes in serum potassium, phosphate, BUN, creatinine, PTH, FGF23, and calcium were assessed in response to 28 days of ASARM peptide infusion. Also, changes in bone quality, soft-tissue calcification, and expression of gut Npt2b (Slc34a2) were studied following ASARM peptide treatment. Results Rats that had undergone 56NEPHREX treated with ASARM peptide showed major improvements in hyperphosphatemia, blood urea nitrogen (BUN), and bone quality compared with vehicle controls. Also, ASARM-infused 56NEPHREX rats displayed improved renal, brain, and cardiovascular calcification. Notably, ASARM peptide infusion prevented the genesis of subdermal medial blood vessel calcification and calciphylaxis-like lesions in 56NEPHREX rats compared with vehicle controls. Conclusions ASARM peptide infusion corrects hyperphosphatemia and improves vascular calcification, renal calcification, brain calcification, bone quality, renal function, and skin mineralization abnormalities in 56NEPHREX rats. These findings confirm our hypothesis and support the utility of ASARM peptide treatment in patients with CKD-MBD.
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Affiliation(s)
- Peter S. Rowe
- The Jared Grantham Kidney Institute, University of Kansas Medical Center, Kansas City, Kansas
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Ellen M. McCarthy
- The Jared Grantham Kidney Institute, University of Kansas Medical Center, Kansas City, Kansas
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Alan L. Yu
- The Jared Grantham Kidney Institute, University of Kansas Medical Center, Kansas City, Kansas
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Jason R. Stubbs
- The Jared Grantham Kidney Institute, University of Kansas Medical Center, Kansas City, Kansas
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
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21
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Pérez Haded I, Bayona D'vera JS, Blanco Espinoza AS, Llamas Castellanos BC, Rolón Cadena MC. Erythema nodosum with incidental calciphylaxis secondary to zoledronic acid and denosumab. Int J Rheum Dis 2022; 25:1441-1443. [DOI: 10.1111/1756-185x.14452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/05/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Iván Pérez Haded
- Dermatology Section Hospital Universitario Fundación Santa Fe de Bogotá Bogotá Colombia
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22
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Zulauf EE, Connors JC, Hardy MA. Manifestation of Nonuremic Calciphylaxis in the Extremities: Case Report and Review. J Foot Ankle Surg 2022; 61:e41-e47. [PMID: 34876341 DOI: 10.1053/j.jfas.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 02/16/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023]
Abstract
Nonuremic calciphylaxis is a rare condition presenting with peripheral ischemic ulcerations. Calciphylaxis is the deposition of calcium and phosphate into arteriolar walls caused by exceeding their solubility range in the blood. It is most commonly seen in patients with end-stage renal disease; however, nonuremic calciphylaxis occurs in patients with normal or mildly impaired renal function. Risk factors for nonuremic calciphylaxis include Coumadin therapy, obesity, and diabetes mellitus. Histopathologic examination of deep skin biopsy containing subcutaneous adipose tissue reveals medial calcification of dermal and subcutaneous arterioles. This diagnosis must be managed locally with wound care and systemically by control of blood calcium solubility. Avoidance of infection is critical to survival. Here we report a case of calciphylaxis in a patient with normal renal function and serum levels of calcium and phosphorus who presented with gangrene of the extremities. Increased awareness of this debilitating disease will lead to earlier diagnosis, proper treatment and improved patient outcomes.
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Affiliation(s)
- Emily E Zulauf
- Grant Medical Center Foot & Ankle Surgery Resident, Columbus, OH.
| | - James C Connors
- Kent State University College of Podiatric Medicine, Independence, OH
| | - Mark A Hardy
- Kent State University College of Podiatric Medicine, Independence, OH
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23
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Kahn C, Singh S, Mathew R, Ramrattan LA, Mohammed IJ, Omman R. Rituximab Used for the Treatment of Nonuremic Calciphylaxis: A Complication of Prolonged Steroid Use in Lupus Nephritis. Cureus 2022; 14:e26516. [PMID: 35795578 PMCID: PMC9250422 DOI: 10.7759/cureus.26516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2022] [Indexed: 11/05/2022] Open
Abstract
Nonuremic calciphylaxis (NUC) is a rare and debilitating form of panniculitis. NUC is associated with a high mortality rate within the first year of diagnosis. Connective tissue diseases account for a small fraction of the reported cases. However, there have also been reported cases of patients developing NUC while on treatment with chronic corticosteroid immunosuppressive therapy. The pathophysiology of NUC is still not fully established. Several risk factors including underlying diseases, obesity, female gender, and medications have been associated with the development of NUC. The diagnosis remains challenging due to the condition's similarities with other forms of panniculitis. The gold standard for diagnosis is a tissue biopsy showing calcifications within the medial layer of arterioles and the presence of microthrombi with surrounding necrosis. The treatment for NUC has not advanced much in recent years and focuses on the management of the underlying condition, wound care, and treating any superimposed infection. Treating superimposed infections remains important as most of the associated mortality from NUC occurs due to sepsis. We describe a case of a young woman with lupus nephritis who developed NUC while on prolonged corticosteroid therapy. She did not respond to several immunosuppressive agents and was ultimately treated with rituximab, a monoclonal antibody against CD20 antigen, as salvage therapy.
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24
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Abstract
Uremic calciphylaxis is a rare disease that affects patients with chronic end-stage renal disease. It is a pathology of the microvessels of the dermis and hypodermis which are calcified and whose thrombosis leads to skin necrosis. Calciphylaxis lesions can be distal and axial. They lead to pain, infection and are associated with denutrition and in high mortality rate (40-80% at 1 year). This general review describes the clinical and para-clinical presentations of calciphylaxis. It summarizes the current knowledge on its pathogenesis and the therapeutical options that can be proposed to improve the management and attempt to reduce the mortality of patients with uremic calciphylaxis.
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25
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Rick J, Strowd L, Pasieka HB, Saardi K, Micheletti R, Zhao M, Kroshinsky D, Shinohara MM, Ortega-Loayza AG. Calciphylaxis: Part I. Diagnosis and pathology. J Am Acad Dermatol 2022; 86:973-982. [PMID: 35114300 DOI: 10.1016/j.jaad.2021.10.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022]
Abstract
Calciphylaxis is an uncommon but devastating disorder characterized by vascular calcification and subsequent cutaneous tissue necrosis. This results in exquisitely painful and slow healing wounds that portend exceptionally high morbidity and mortality. The diagnosis of this condition can be complicated because there are no conclusive serologic, radiographic or visual signs that this disease is manifesting. The differential of tissue necrosis is broad, and identifying calciphylaxis requires an adroit understanding of the risk factors and physical signs that should raise suspicion of this condition. Reviews on this subject are uncommon and lack directed commentary from disease experts on the best diagnostic approach for patients suffering from this disease. The goal of this article is to update practicing dermatologists on the current standard of care for calciphylaxis.
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Affiliation(s)
- Jonathan Rick
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lindsay Strowd
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Helena B Pasieka
- Georgetown University School of Medicine, Washington, DC; Uniformed Services University School of Medicine, Bethesda, Maryland
| | - Karl Saardi
- Georgetown University School of Medicine, Washington, DC
| | - Robert Micheletti
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Megan Zhao
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Michi M Shinohara
- University of Washington Division of Dermatology, Seattle, Washington
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26
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Godbe K, Elver A, Chow P, Williams C, Fraga G, Harris P, Taha M, Bhavsar D, Korentager R. Case Report: Idiopathic Subcutaneous Thrombotic Vasculopathy. Front Med (Lausanne) 2022; 9:843793. [PMID: 35492355 PMCID: PMC9051404 DOI: 10.3389/fmed.2022.843793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Lower extremity ulcers have significant morbidity, with treatment determined by the underlying disorder. Reported is a 32-year-old female presenting with small skin nodules and bruises across her legs 4 weeks following her second COVID vaccination. These lesions progressed into large, necrotic ulcers over several months. Initial work-up showed widespread pannicular thrombotic vasculopathy with ischemic skin necrosis. The tissue was negative for calcification on Von Kossa histochemistry, and a working diagnosis of subcutaneous thrombotic vasculopathy was suggested. The ulcers progressed despite treatments with corticosteroids, therapeutic anticoagulation, intravenous immunoglobulin, plasmapheresis, sodium thiosulfate, wound care, and repeat debridement. Later debridement specimens demonstrated rare vascular and pannicular calcifications. This finding supports the hypothesis that subcutaneous thrombotic vasculopathy is a precursor to calciphylaxis, the patient’s current working diagnosis. However, based on the patient’s entire clinical picture, a definitive diagnosis has yet to be found. This report highlights the challenges of working with rare diseases and the importance of multidisciplinary cooperation.
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Affiliation(s)
- Kerilyn Godbe
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, United States
| | - Ashlie Elver
- University of Kansas School of Medicine, Kansas City, KS, United States
| | - Peter Chow
- Department of Dermatology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Chris Williams
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Garth Fraga
- Department of Pathology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Penelope Harris
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Mohammed Taha
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Dhaval Bhavsar
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, United States
| | - Richard Korentager
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, United States
- *Correspondence: Richard Korentager,
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27
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Castillo FT, Seth D, Agnihothri R, Fox L, North J, Haemel A. Nonuremic Calciphylaxis Manifesting with Diffuse Dermal Angiomatosis. JAAD Case Rep 2022; 24:8-10. [PMID: 35518276 PMCID: PMC9062726 DOI: 10.1016/j.jdcr.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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28
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Reolid A, Martínez-Palazuelo M, Rodríguez-Jiménez P, Muñoz-Aceituno E, Llamas-Velasco M, Fraga J, Daudén E. Cutaneous vascular calcification. Peri-eccrine calcification as a diagnostic key for calciphylaxis. J Cutan Pathol 2022; 49:683-691. [PMID: 35357702 DOI: 10.1111/cup.14234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/17/2022] [Accepted: 03/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Attempts have been made to establish discriminative criteria between classic calciphylaxis (CPX) and those cases in which cutaneous vascular calcification (CVC) represents an incidental finding (epiphenomenon). METHODS Retrospective, observational cohort study of patients with CVC with the aim of distinguishing clinicopathological features between CVC as classic CPX (CVC in cutaneous lesions with erythemato-violaceous plaques with or without ulceration) or as epiphenomenon (CVC in cutaneous lesions with known diagnosis). Different clinicopathological parameters and presence of perieccrine calcification and pseudoxanthoma-elasticum (PXE)-like changes were evaluated. RESULTS Sixty-six patients were studied. The CPX group showed a significantly higher percentage of renal failure, hypertension, altered laboratory parameters, painful lesions and mortality rate. Histopathologically, the CPX group was associated with more than one vessel per field involved with subintimal concentric calcification and perieccrine calcification (observed exclusively in CPX group), while PXE changes, although more frequent in the CPX group, were also observed in the epiphenomenon group. CONCLUSIONS Perieccrine calcification and the presence of more than one vessel per field involved by concentric pattern calcification could be used as a diagnostic marker of CPX. Although PXE-like changes are not an exclusive marker, they could suggest CPX diagnosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- A Reolid
- Dermatology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa (IIS-IP), Madrid, Spain
| | - M Martínez-Palazuelo
- Dermatology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa (IIS-IP), Madrid, Spain
| | - P Rodríguez-Jiménez
- Dermatology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa (IIS-IP), Madrid, Spain
| | - E Muñoz-Aceituno
- Dermatology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa (IIS-IP), Madrid, Spain
| | - M Llamas-Velasco
- Dermatology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa (IIS-IP), Madrid, Spain
| | - J Fraga
- Pathology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Madrid, Spain
| | - E Daudén
- Dermatology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa (IIS-IP), Madrid, Spain
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Guillén-Olmos E, Torregrosa JV, Garcia-Herrera A, Ganau S, Diekmann F, Cucchiari D. Development of calciphylaxis in kidney transplant recipients with a functioning graft. Clin Kidney J 2022; 15:663-671. [PMID: 35371461 PMCID: PMC8967679 DOI: 10.1093/ckj/sfab205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background Calciphylaxis is not uniquely observed in uraemic patients, as some cases have also been reported in patients with normal renal function or moderate chronic kidney disease (CKD), in association with severe vasculopathy or systemic inflammation. A particular subset worthy of studying is represented by those patients who develop calciphylaxis after kidney transplantation (KT). Methods Analysis of the local series of calciphylaxis after KT (n = 14) along with all the other cases reported in the literature from 1969 to 2019 (n = 31), for a total population of 45 patients, is presented. Demographic data, CKD history, risk factors, immunosuppression, clinical presentation and management have been analysed both as a whole and according to the time period (before or after the year 2000). Results Calciphylaxis developed during the first year after KT in 43.2% of patients and median (interquartile range) creatinine at diagnosis was 2.4 (1.25–4.64) mg/dL. The most frequent presentation included distal purpura or ulcers in one-third of cases and 39.1% of patients were receiving vitamin K antagonists. PTH values were above 500 pg/mL and below 100 pg/mL in 50.0% and 25.0% of cases, respectively. Whole population mortality was 55.6%. As expected, clinical presentation, immunosuppression and management varied depending on the time period. Patients diagnosed after 2000 were older, with longer dialysis vintage, and treatment was usually multimodal; on the contrary, in patients diagnosed before 2000, parathyroidectomy was the treatment of choice in 61.9% of cases. Conclusions Calciphylaxis can still occur after KT, in many cases during the first year and in patients with a good renal function. Risk factors and management varied according to the time period studied.
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Affiliation(s)
- Elena Guillén-Olmos
- Nephrology and Renal Transplantation Department, Hospital Clínic, Barcelona, Spain
| | | | | | - Sergi Ganau
- Radiology Department, Hospital Clínic, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplantation Department, Hospital Clínic, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - David Cucchiari
- Nephrology and Renal Transplantation Department, Hospital Clínic, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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30
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Shuman H, Obri MS, Artz C, Fadel R, Williams J. Nonuremic Calciphylaxis Precipitated by COVID-19 Infection. Cureus 2022; 14:e22796. [PMID: 35382212 PMCID: PMC8976412 DOI: 10.7759/cureus.22796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 11/05/2022] Open
Abstract
Calciphylaxis is a rare dermatologic condition that is primarily associated with end-stage renal disease (ESRD). Nonuremic calciphylaxis has been reported in patients with autoimmune disorders such as systemic lupus erythematosus and other hypercoagulable states such as anti-phospholipid syndrome. New research throughout the COVID-19 pandemic has shown an increased inflammatory and coagulopathic complication of COVID-19. We present a case of a patient with nonuremic calciphylaxis following treatment for severe COVID-19 and no known cause of hypercoagulability. A 40-year-old Caucasian female with a history of recent COVID-19 infection requiring hospitalization, hypertension, alcohol abuse, anxiety, and one prior spontaneous miscarriage presented to the hospital with bilateral lower extremity wounds. The wounds were seen to have necrosis and eschar formation, as well as blackened mottled skin, and were extremely painful to the patient. The initial lesions were on the anterior thighs bilaterally and spread laterally and to the lower back. Initial autoimmune workup was non-specific, and biopsy confirmed calciphylaxis. Calciphylaxis is a known dermatologic disease that has high mortality and morbidity, but it is usually associated with ESRD. Some cases have been reported for autoimmune or hypercoagulable states. The disease presents with non-healing, painful skin ulcers that are at a high risk of infection and have poor healing. The case presented shows biopsy-confirmed calciphylaxis in the absence of known etiologies, and we hypothesize that it is due to COVID-19 or COVID-19 aggravating an underlying but unidentified hypercoagulable condition.
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31
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Kim J, Konkel K, Jones SC, Reyes M, McCulley L. Teriparatide-associated calciphylaxis: a case series. Osteoporos Int 2022; 33:499-504. [PMID: 34494145 PMCID: PMC8813882 DOI: 10.1007/s00198-021-06139-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/28/2021] [Indexed: 11/28/2022]
Abstract
Calciphylaxis is a rare and potentially fatal small-vessel occlusive disease in which the tunica media becomes calcified, endothelial cells proliferate, and the tunica intima becomes thickened and fibrotic. Calciphylaxis typically occurs in the setting of end-stage renal disease with secondary hyperparathyroidism and elevated calcium-phosphorus product. The estimated incidence of calciphylaxis in dialysis or kidney transplant patients is 1 to 4%; however, the incidence of non-uremic calciphylaxis is unknown. We assessed postmarketing adverse event reports to further characterize cases of calciphylaxis associated with teriparatide. We searched for cases of teriparatide-associated calciphylaxis in the literature (EMBASE, PubMed) and those reported to FDA, including the FDA Adverse Event Reporting System, through March 31, 2021. We included calciphylaxis cases following teriparatide exposure of < 2 years. Twelve cases described teriparatide-associated calciphylaxis. The median age was 81 (range 47-86) years. Eleven cases reported confirmatory biopsy and/or imaging. The median time-to-onset of calciphylaxis following teriparatide initiation was 3.5 (range 1-20) months. Three cases reported hospitalization, of which one resulted in death due to progression of the lesions. All cases had multiple risk factors (mean (SD), 4.5 (1.0)) including concomitant medications associated with calciphylaxis (12), female sex (11), and/or underlying autoimmune disease or other inflammatory disorder (10). We believe that exposure to teriparatide, coupled with underlying risk factors, may have triggered new-onset calciphylaxis. Expedited diagnosis and management by a clinician are important because calciphylaxis may be life-threatening and early intervention may improve outcomes.
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Affiliation(s)
- J Kim
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
| | - K Konkel
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - S C Jones
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - M Reyes
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - L McCulley
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
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Smilnak G, Jiang M, Jain B. Calciphylaxis of the penis and distal digits: a case report. J Med Case Rep 2022; 16:18. [PMID: 35039083 PMCID: PMC8764786 DOI: 10.1186/s13256-021-03231-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Calciphylaxis is a rare, often fatal disease resulting from calcification of dermal arterioles and capillaries. Usually diagnosed in patients with end-stage renal disease, this disorder typically presents as necrotic, nonhealing ulcers in acral or adipose areas. Here we report the case of an elderly man who was found to have calciphylaxis of the distal digits and penis, the latter of which is an uncommon site of disease that carries a particularly poor prognosis. Case presentation A 73-year-old African American man with multiple medical comorbidities including dialysis-dependent end-stage renal disease presented with worsening painful, necrotic lesions on his glans penis and several distal digits over the last 2 months. The wound on the glans was foul smelling with overlying purulence and had been unsuccessfully treated with amoxicillin–clavulanic acid. Discovery of diffuse intravascular calcification on computed tomography, in addition to a markedly elevated calcium–phosphate product immediately prior to the onset of his ulcers, led to the diagnosis of calciphylaxis. The patient was initiated on sodium thiosulfate without improvement in his lesions, and he died 3 months later after another prolonged hospitalization. Conclusions While calciphylaxis is a rare disease, involvement of the distal digits and especially the penis is even more uncommon and portends a particularly poor prognosis: 6-month mortality rates are reportedly as high as 70%. This suggests that prompt recognition and management of the disease is required; however, despite receiving standard therapy, our patient failed to experience improvement in his disease and instead developed several more fingertip ulcers at blood glucose sample points during his hospitalization. A corollary of the case presented here is the need for more effective management of calciphylaxis, especially for patients in whom uncommon sites, such as the penis, are involved.
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Affiliation(s)
- Gordon Smilnak
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael Jiang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Hospital Medicine at Jesse Brown VAMC, Northwestern University Feinberg School of Medicine, 820 S Damen Ave, Suite 7566, Chicago, IL, 60612, USA
| | - Bijal Jain
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Hospital Medicine at Jesse Brown VAMC, Northwestern University Feinberg School of Medicine, 820 S Damen Ave, Suite 7566, Chicago, IL, 60612, USA.
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[Skin lesions in probable relation to non-uremic calciphylaxis in an octogenarian patient: Clinical case and review of the literature]. Rev Esp Geriatr Gerontol 2021; 57:46-48. [PMID: 34930635 DOI: 10.1016/j.regg.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/20/2021] [Accepted: 10/26/2021] [Indexed: 11/22/2022]
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Gabel CK, Blum AE, François J, Chakrala T, Dobry AS, Garza-Mayers AC, Ko LN, Nguyen ED, Shah R, John JS, Nigwekar SU, Kroshinsky D. Clinical mimickers of calciphylaxis: A retrospective study. J Am Acad Dermatol 2021; 85:1520-1527. [PMID: 33744358 DOI: 10.1016/j.jaad.2021.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/25/2021] [Accepted: 03/06/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Calciphylaxis is an ischemic vasculopathy with high morbidity and mortality. Early and accurate diagnosis is critical to management of calciphylaxis. Clinical mimickers may contribute to delayed or misdiagnosis. OBJECTIVE To assess the rate and risk factors for misdiagnosis and to identify clinical mimickers of calciphylaxis. METHODS A retrospective medical record review was conducted of patients with calciphylaxis at a large urban tertiary care hospital between 2006 and 2018. RESULTS Of 119 patients diagnosed with calciphylaxis, 73.1% were initially misdiagnosed. Of patients not initially misdiagnosed, median time to diagnosis from initial presentation was 4.5 days (interquartile range, 1.0-23.3), compared to 33 days (interquartile range, 13.0-68.8) in patients who were initially misdiagnosed (P = .0002). The most common misdiagnoses were cellulitis (31.0%), unspecified skin infection (8.0%), and peripheral vascular disease (6.9%). Patients who were misdiagnosed frequently received at least 1 course of antibiotics. Patients with end-stage renal disease were less likely to be misdiagnosed than those without this disease (P = .001). LIMITATIONS Single-center, retrospective study. CONCLUSIONS Understanding the risk factors for misdiagnosis of calciphylaxis is an opportunity for further education concerning this rare disease.
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Affiliation(s)
- Colleen K Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy E Blum
- Harvard Medical School, Boston, Massachusetts
| | | | - Teja Chakrala
- Narayana Medical College and Hospital, Nellore, India
| | - Allison S Dobry
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine, California
| | | | - Lauren N Ko
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Emily D Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jessica St John
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sagar U Nigwekar
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts.
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Ababneh EI, Hassanein M, Saad AM, Cook EE, Ko JS, Fatica RA, Vachharajani TJ, Fernandez AP, Billings SD. Calciphylaxis in uraemic and nonuraemic settings: clinical risk factors and histopathological findings. Clin Exp Dermatol 2021; 47:700-708. [PMID: 34762763 DOI: 10.1111/ced.15009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Calciphylaxis is a life-threatening cutaneous ulcerative/necrotic disease characterized by vascular calcification/occlusion. It occurs most commonly in end-stage kidney disease (ESKD), known as uraemic calciphylaxis (UC) but can also occur in patients with chronic kidney disease (CKD) and normal kidney function (nonuraemic calciphylaxis; NUC). There are few large series of NUC in the literature. AIM To compare the clinicopathological features of UC and NUC. METHODS We retrospectively compared the clinicopathological features of 35 patients with NUC during the period 2010-2020 with those of 53 patients with UC (control group). Cases were classified as NUC in the absence of all of the following: ESKD, significant CKD (defined as serum creatinine > 3 mg/dL or creatinine clearance < 15 mL/min) and acute kidney injury requiring kidney replacement therapy or kidney transplantation. RESULTS NUC represented 40% of the total cases, and there was a higher number of women (P < 0.01) and a higher median body mass index (P = 0.06) compared with the control UC group. Elevated parathyroid hormone was present in 44% of patients with NUC. Most of the tested patients were positive for lupus anticoagulants (56%). NUC biopsies showed a higher rate of extravascular calcium deposits (73% vs. 47%, P = 0.03). Dermal reactive vascular proliferation was the most common dermal change (32%). CONCLUSIONS NUC is more common than previously reported and shows a higher predilection for obese postmenopausal women. Undiagnosed hyperparathyroidism shows a possible association with NUC. Lupus anticoagulants were positive in most patients. NUC biopsies are more likely than UC biopsies to display extravascular calcium deposition.
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Affiliation(s)
- E I Ababneh
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - M Hassanein
- Department of, Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA.,Department of, Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - A M Saad
- Department of, Dermatology, Cleveland Clinic, Cleveland, OH, USA.,Department of Nephrology and Hypertension, University of Mississippi Medical Center, Mississippi, MO, USA
| | - E E Cook
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - J S Ko
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - R A Fatica
- Department of, Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - T J Vachharajani
- Department of, Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - A P Fernandez
- Department of Pathology, Detroit Medical Center, Detroit, MI, USA
| | - S D Billings
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Calcific uremic arteriolopathy, termed calciphylaxis, was previously considered a condition that developed mostly in patients requiring dialysis. It has now been described in kidney transplant patients, in advanced chronic kidney disease (CKD) patients not requiring dialysis, and in individuals with maintained kidney function. We describe an individual with CKD stage 3b with hypercalcemia who presented with features highly specific for calciphylaxis based on results of a skin biopsy. The condition has high morbidity and mortality, and thus prompts immediate cessation of the offending agents or treatment of the cause. The following case and literature review demonstrates a need for a detailed assessment of patients’ risks and exposures and expanding the differential diagnosis to include calciphylaxis in nonuremic patients with necrotic ulcers with a plan for early imaging and possible biopsy.
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Raj R, Elshimy G, Mishra R, Jha N, Joseph V, Bratman R, Tella SH, Correa R. Dermatologic Manifestations of Endocrine Disorders. Cureus 2021; 13:e18327. [PMID: 34692360 PMCID: PMC8526081 DOI: 10.7759/cureus.18327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/05/2022] Open
Abstract
Endocrine disorders are known to involve all organ systems of the body, including the skin. The cutaneous manifestations of endocrine disorders can range from common findings such as acanthosis nigricans, pretibial myxedema, acne, hirsutism, hyper or hypopigmentation to rare cutaneous findings such as miliaria rubra, calciphylaxis, lentigines, and calcinosis cutis. These cutaneous symptoms can sometimes be the presenting symptoms or can even be pathognomonic of the underlying endocrine condition. In some cases, the cutaneous symptoms from an underlying endocrine abnormality may be the most prominent. These symptoms can significantly affect the quality of life of individuals. Often, individuals may seek health care from a dermatologist or primary care physician for isolated skin symptoms. Therefore, it is imperative for physicians to recognize the skin symptoms as the manifestation of the endocrine disorder for prompt diagnosis and treatment of the underlying endocrine disorder.
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Affiliation(s)
- Rishi Raj
- Endocrinology, Diabetes and Metabolism, Pikeville Medical Center, Pikeville, USA
| | - Ghada Elshimy
- Endocrinology, Diabetes and Metabolism, Augusta University Medical College of Georgia, Augusta, USA
| | - Rahul Mishra
- Internal Medicine, Maulana Azad Medical College, Delhi, IND
| | - Nivedita Jha
- Internal Medicine, Adichunchanagiri Institute of Medical Sciences, Karnataka, IND
| | - Vismaya Joseph
- Data Science, University of Texas at Dallas, Richardson, USA
| | - Russell Bratman
- Endocrinology, Diabetes and Metabolism, Brown University, Rhode Island, USA
| | | | - Ricardo Correa
- Endocrinology, Diabetes and Metabolism, University of Arizona College of Medicine - Phoenix, Phoenix, USA
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Mohandas R, Chamarthi G, Segal MS. Nonatherosclerotic Vascular Abnormalities Associated with Chronic Kidney Disease. Cardiol Clin 2021; 39:415-425. [PMID: 34247754 DOI: 10.1016/j.ccl.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nonatherosclerotic vascular diseases are manifested by endothelial dysfunction, hypertension, vascular calcification, coronary microvascular dysfunction, and calciphylaxis. Unfortunately, there are no definitive treatments for many of these disorders other than hypertension. In addition, although hypertension is more difficult to treat in the chronic kidney disease population, it is necessary to try and target a blood pressure of less than 130/80 mm Hg through the use of aggressive angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, diuretics, and other antihypertensive medications. New therapies are being actively investigated in an attempt to treat nonatherosclerotic vascular diseases in the chronic kidney disease population.
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Affiliation(s)
- Rajesh Mohandas
- Division of Nephrology, Hypertension & Transplantation, University of Florida College of Medicine, CG-98, 1600 Archer Road, Gainesville, FL 32610, USA; Nephrology and Hypertension Section, Gainesville Veterans Administration Medical Center, CG-98, 1600 Archer Road, Gainesville, FL 32610, USA
| | - Gajapathiraju Chamarthi
- Division of Nephrology, Hypertension & Transplantation, University of Florida College of Medicine, CG-98, 1600 Archer Road, Gainesville, FL 32610, USA
| | - Mark S Segal
- Division of Nephrology, Hypertension & Transplantation, University of Florida College of Medicine, CG-98, 1600 Archer Road, Gainesville, FL 32610, USA; Nephrology and Hypertension Section, Gainesville Veterans Administration Medical Center, CG-98, 1600 Archer Road, Gainesville, FL 32610, USA.
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Sethupathi SK, Piontek J, Burkemper N, Reinberg J, Chaudhry SB. Atypical presentation of nonuremic calciphylaxis in a female patient with metastatic breast cancer. Int J Womens Dermatol 2021; 7:363-364. [PMID: 34222602 PMCID: PMC8243132 DOI: 10.1016/j.ijwd.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/24/2020] [Accepted: 12/15/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Jessica Piontek
- Department of Dermatology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Nicole Burkemper
- Department of Dermatology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | | | - Sofia B. Chaudhry
- Department of Dermatology, Saint Louis University School of Medicine, St. Louis, MO, United States
- Corresponding author.
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40
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Zenati N, Khouri C, Schwebel C, Blaise S. Skin necrosis and calcifications after extravasation of vancomycin: a localised form of calciphylaxis? J Wound Care 2021; 30:390-393. [PMID: 33979216 DOI: 10.12968/jowc.2021.30.5.390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Vancomycin is a tricyclic glycopeptide antibiotic produced from Streptococcus orientalis. There is much variation in the literature with regard to the recommended dose, dilution rate and type of infusion. Given the vesicant properties of vancomycin at supratherapeutic doses (>10mg/ml), tissue damage including blistering and necrosis have been reported. We report a rare case of bilateral cutaneous necrosis induced by accidental extravasation of vancomycin when being intravenously administered. The skin surrounding the injection site was marked by the appearance of subcutaneous calcifications. The development of iatrogenic skin calcinosis has not yet been described for the extravasation of vancomycin. The mechanism underlying the calcinosis observed in our case remains unclear, but we hypothesised a form of localised calciphylaxis induced by a local triggering factor. The ulcers progressed to re-epithelialisation following necrosis debridement and local conservative treatments. Given the increased prevalence of meticillin-resistant Staphylococcus aureus, which has prompted clinicians to gradually increase vancomycin dosage, clinicians should be aware of the high risk of skin toxicity in cases of vancomycin high-dose extravasation.
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Affiliation(s)
- Nora Zenati
- Grenoble University Hospital, Department of Vascular Medicine, F-38000 Grenoble, France
| | - Charles Khouri
- Grenoble Alpes University Hospital, Pharmacovigilance Unit, F-38000 Grenoble, France.,Grenoble Alpes University Hospital, Clinical Pharmacology Department, INSERM CIC1406, F-38000 Grenoble, France.,Univ. Grenoble Alpes, UMR 1042-HP2, INSERM, F-38000 Grenoble, France
| | - Carole Schwebel
- Medical Intensive Care Unit, Grenoble University Hospital, F-38000 Grenoble, France
| | - Sophie Blaise
- Grenoble University Hospital, Department of Vascular Medicine, F-38000 Grenoble, France.,Univ. Grenoble Alpes, UMR 1042-HP2, INSERM, F-38000 Grenoble, France
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41
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Ruderman I, Toussaint ND, Hawley CM, Krishnasamy R, Pedagogos E, Lioufas N, Elder GJ. The Australian Calciphylaxis Registry: reporting clinical features and outcomes of patients with calciphylaxis. Nephrol Dial Transplant 2021; 36:649-656. [PMID: 31855262 DOI: 10.1093/ndt/gfz256] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/17/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Calciphylaxis is a rare disease, predominantly affecting patients with chronic kidney disease (CKD) and associated with significant morbidity and mortality due to progressive cutaneous calcification, necrotic ulceration and infection. Clinical registries have been established to better understand the risk factors, optimal treatments and disease outcomes of calciphylaxis. METHODS We established a prospective, Internet-based clinical registry for the online notification of calciphylaxis cases in Australia. Seven institutions participated, with data recorded on patient characteristics, biochemical parameters, treatments and disease outcomes. RESULTS Between 2014 and 2019, 47 cases of calciphylaxis were registered. The mean patient age was 66 ± 11 years and body mass index was 35 ± 9 kg/m2, with a higher proportion of females (51%). Eighty-seven percent of patients had end-stage kidney disease (ESKD), with 61% on hemodialysis or hemodiafiltration, with a median dialysis vintage of 4.8 [interquartile range (IQR) 1.7-7.4)] years. Five patients had CKD not requiring dialysis and two were kidney transplant recipients. Diabetes was present in 76% of patients and the cause of ESKD in 60%; 34% received vitamin K antagonists (VKAs) before diagnosis. The median parathyroid hormone level at diagnosis was 32 (IQR 14-50) pmol/L. The most common site of calciphylaxis was the lower limbs (63%), with 19% of patients having more than one area involved. Ten patients (22%) had a resolution of calciphylaxis and 25 died, with 50% mortality at a median of 1.6 (IQR 0.2-2.5) years from diagnosis. CONCLUSIONS The Australian Calciphylaxis Registry highlights risk factors for calciphylaxis, including diabetes, obesity and VKA use. Resolution of calciphylaxis is uncommon despite multimodal therapy and mortality from calciphylaxis in the first year following diagnosis remains high.
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Affiliation(s)
- Irene Ruderman
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Australasian Kidney Trial Network, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast Hospital University Hospital, Birtinya, Queensland, Australia
| | - Eugenia Pedagogos
- Department of Nephrology, Western Health, Melbourne, Victoria, Australia
| | - Nicole Lioufas
- Department of Nephrology, Western Health, Melbourne, Victoria, Australia
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
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Turek M, Stępniewska J, Różański J. The Multifactorial Pathogenesis of Calciphylaxis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930026. [PMID: 34097671 PMCID: PMC8197444 DOI: 10.12659/ajcr.930026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Female, 52-year-old Final Diagnosis: Calciphylaxis Symptoms: Skin nodules • ulceration Medication: — Clinical Procedure: — Specialty: General and Internal Medicine • Nephrology
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Affiliation(s)
- Marta Turek
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Joanna Stępniewska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Jacek Różański
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
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Doraiswamy M, Singh P, Pesavento TE, Meng S. Complete resolution of calciphylaxis in a renal transplant patient with Calcifediol. Postgrad Med J 2021; 98:e35. [PMID: 37063028 DOI: 10.1136/postgradmedj-2021-139854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Mohankumar Doraiswamy
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Priyamvada Singh
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Todd E Pesavento
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Shumei Meng
- Division of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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DeClue C, Chinnakotla B, Gardner MJ. Non-Uremic Calciphylaxis: An Unexpected Complication With Recombinant Human Parathyroid Hormone. Cureus 2021; 13:e15014. [PMID: 34150377 PMCID: PMC8202451 DOI: 10.7759/cureus.15014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Calciphylaxis is a rare syndrome of calcific microvascular occlusion, whereas non-uremic calciphylaxis (NUC) is a subset of this disease in which renal impairment is not observed. Recombinant human parathyroid hormone (rhPTH) (1-84) is a medication approved for the management of hypocalcemia in patients with hypoparathyroidism. We present a case report of a 38-year-old woman with postoperative hypoparathyroidism treated with rhPTH who subsequently developed calciphylactic lesions on her abdomen. Multidisciplinary interventions included intravenous and intralesional sodium thiosulfate therapy, laboratory monitoring, dermatological wound care, and pain management. Calciphylaxis can rarely be precipitated by rhPTH due to its effect on calcium and phosphorus balance even in the setting of normal renal function. The use of calcium and calcitriol supplementation, complicated by factors such as female sex and obesity, may have contributed in this patient’s case. Hence, regular follow-up with tapering off of calcium and calcitriol supplementation is important in patients receiving rhPTH.
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Affiliation(s)
- Cory DeClue
- Internal Medicine, University of Missouri, Columbia, USA
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Development of the BWAT-CUA Scale to Assess Wounds in Patients with Calciphylaxis. Diagnostics (Basel) 2021; 11:diagnostics11040730. [PMID: 33924020 PMCID: PMC8073812 DOI: 10.3390/diagnostics11040730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/09/2021] [Accepted: 04/11/2021] [Indexed: 11/26/2022] Open
Abstract
Calcific uremic arteriolopathy (CUA; calciphylaxis) is a severe form of vascular calcification with no approved therapies. A standardized wound assessment tool is needed to evaluate changes in calciphylaxis wounds over time. A prospective, single-arm study of 14 patients with calciphylaxis reported improvement for the primary endpoint of wound healing using the 13-item Bates-Jensen Wound Assessment Tool (BWAT), although that tool was developed for assessment of pressure ulcers. This report describes development of BWAT-CUA, an 8-item modification of BWAT focusing on prototypical features of calciphylaxis lesions. The BWAT-CUA has a range of 8 (best) to 40 (worst) and was used ad hoc to analyze BWAT data collected in the prospective study. Using BWAT-CUA, relative improvement in calciphylaxis wounds was 30% overall (from 21.2 to 14.9; p = 0.0016) and 34% in the subset of 12 patients with ulceration at baseline (from 23.3 to 15.3; p = 0.0002). BWAT-CUA is a primary endpoint in an ongoing randomized, placebo-controlled phase 3 study of SNF472 recruiting patients with end-stage kidney disease and at least one ulcerated calciphylaxis lesion. BWAT-CUA, a newly developed tool for assessment of calciphylaxis wound severity and improvements over time, may be used in clinical research and in clinical practice.
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Shahzad SR, Alfaris F, Arslan ME, Mehta S. Early onset calciphylaxis following acute kidney injury secondary to anti-glomerular basement membrane antibody disease. BMJ Case Rep 2021; 14:14/4/e241265. [PMID: 33827879 PMCID: PMC8030672 DOI: 10.1136/bcr-2020-241265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Calciphylaxis is commonly associated with end-stage renal disease (ESRD) and renal transplant. We present a rare case of early onset calciphylaxis in a patient presenting with acute kidney injury (AKI) secondary to anti-glomerular basement membrane (anti-GBM) antibody disease. A 65-year-old obese Caucasian woman with type 2 diabetes mellitus and hypertension presented with a 1-month history of painless gross haematuria and worsening lower extremity oedema. Laboratory results indicated AKI and nephrotic-range proteinuria. Anti-glomerular antibodies were elevated. Renal biopsy revealed focal crescentic glomerulonephritis with linear capillary immunoglobulin G staining consistent with anti-GBM antibody disease. She was treated with haemodialysis, plasmapheresis, steroids, bumetanide and cyclophosphamide. Two months later, she developed necrotic lesions on bilateral thighs. Wound biopsy was consistent with calciphylaxis. This case highlights that calciphylaxis, usually seen in patients with chronic kidney disease or ESRD, can manifest in patients with AKI as well.
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Affiliation(s)
| | - Faris Alfaris
- Nephrology and Hypertension, Albany Medical Center Hospital, Albany, New York, USA
| | | | - Swati Mehta
- Nephrology and Hypertension, Albany Medical Center Hospital, Albany, New York, USA
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Nseir V, Bradauskaite G, Pedroza M, Minimo C, Zaki R, Chewaproug D. A Rare Case of Calciphylaxis in an Orthotopic Liver Transplant Recipient with Acute Kidney Injury. EXP CLIN TRANSPLANT 2021; 19:382-385. [DOI: 10.6002/ect.2017.0123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hodson M, Kaur G, Lin G, Coates A. Non-uremic calciphylaxis in a woman without end-stage renal disease. BMJ Case Rep 2021; 14:e239225. [PMID: 33637497 PMCID: PMC7919574 DOI: 10.1136/bcr-2020-239225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 11/04/2022] Open
Abstract
A woman in her 60s with a history of lower extremity vascular disease presented with extreme pain and wounds in her legs which had kept her from walking for several weeks. The patient's pain became intolerable throughout her hospital stay despite multiple surgical revascularisations. Biopsy of the patient's calf wounds revealed evidence of calciphylaxis, a diagnosis which corresponds with this patient's extreme pain. Our patient had no history of end-stage renal disease.
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Affiliation(s)
| | | | - George Lin
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Andrew Coates
- Department of Internal Medicine, Albany Medical Center, Albany, NY, USA
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Calcific Uremic Arteriolopathy: A Case Series and Review from an Inner-City Tertiary University Center in End-Stage Renal Disease Patients on Renal Replacement Therapy. Int J Nephrol 2021; 2021:6661042. [PMID: 33628505 PMCID: PMC7895580 DOI: 10.1155/2021/6661042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/18/2022] Open
Abstract
Materials and Methods 24 patients with CUA and on RRT were evaluated at Detroit Medical Center from 2007 to 2016. Skin biopsy was used in almost all patients, along with the radiological and clinical findings. The patient's clinical and paraclinical data were retrieved from the electronic medical records. The effect of treatment modalities and the underlying hyperparathyroidism management were compared to the clinical outcomes using appropriate statistical tests. Results Twenty-one patients were on hemodialysis, two patients received renal transplants, and one patient was on peritoneal dialysis. Diabetes mellitus was the most prevalent cause of ESRD. The parathyroid hormone level (PTH) was elevated in 22 patients. Fifteen patients were diagnosed 2 weeks or more prior to skin lesion onset. Twenty-two and thirteen patients received sodium thiosulphate and cinacalcet, respectively. Patients with lower PTH and the calcium-phosphate product levels had a relatively better outcome of CUA. Conclusions A multifaceted approach may play a role in treating CUA. Referral to a nephrologist may aid in the early diagnosis and prompt management of CUA.
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