Painful skin lesion in a patient on haemodialysis: a diagnosis not to miss

An 81-year-old man was admitted under the care of a plastic surgery team with a 10-day history of a painful left lower leg skin lesion after a punch biopsy of a naevus. His background history includes end-stage kidney disease secondary to hypertensive nephropathy, on intermittent haemodialysis via fistula. Other significant background history includes stroke, hypertension and ischaemic heart disease with coronary artery stents. There was no history of warfarin use. He was initially treated with a 5-day course of oral antibiotics with no improvement. He was referred to the hospital where he was admitted under the plastic surgery team who had completed the punch biopsy for intravenous antibiotics for presumed cellulitis. During his admission, the nephrology service were consulted to prescribe routine inpatient haemodialysis. Further history taking and wound review identified a 10-day history of an extremely painful skin lesion with an eschar and surrounding dusky, purpuric skin. Given the disproportionate pain and black eschar which are not in keeping with cellulitis, a diagnosis of calciphylaxis was made. He was commenced sodium thiosulfate on haemodialysis.

Calcinosis cutis in a renal transplant patient

Calcinosis cutis is an unusual disorder characterised by calcium-phosphate deposition into cutaneous and subcutaneous tissues. There are five subtypes: dystrophic, metastatic, idiopathic, iatrogenic and calciphylaxis. Our objective was to report a patient with a history of haemodialysis-dependent end-stage renal disease (ESRD) who developed metastatic calcinosis cutis, which is usually associated with abnormalities of calcium-phosphate metabolism in renal failure. In our patient, the serum calcium and phosphate levels were normal. Additionally, we describe the diagnostic approach and the difficulties involved in the management of calcinosis cutis in patients with haemodialysis-dependent ESRD.

[When necrosis threatens the kidney patient…]

Calciphylaxis is a rare but devastating condition characterized by a calcifying thrombosing microangiopathy resulting in painful necrotic skin lesions. Risk factors are multiple, the most important being obesity, disorders of phosphocalcic metabolism and acenocoumarol. Largely unknown by the medical community, its pathogenesis is still incompletely elucidated; its diagnosis by skin biopsy remains difficult and increasingly debated because potentially associated with an aggravation of lesions. Its treatment must be as premature as possible andmultimodal. However, the results are up to now unsatisfactory, as specific treatment of calciphylaxis does not yet exist.

Penile calciphylaxis: a conservative approach

Penile calciphylaxis or calcific uremic arteriolopathy is a rare urological condition often associated with patients undergoing renal dialysis for end-stage renal disease. The majority of cases are associated with systemic calciphylaxis. The pathophysiology, diagnosis and management of penile calciphylaxis as an individual entity has brought little attention. The rates of comorbidity and mortality of these patients are often particularly high. Early diagnosis and a multidisciplinary approach are therefore essential. We report a case of penile calciphylaxis in a 59-year-old man with end-stage renal failure on haemodialysis who was successfully managed conservatively.

Calciphylaxis in Association with Alcoholic Cirrhosis and Hepatorenal Syndrome

A 45-year-old woman with cirrhosis secondary to alcohol abuse was transferred from an outside hospital for management of a painful cutaneous eruption, progressively worsening over 2 weeks. On examination, the patient was a middle-aged white woman lying in bed in no acute distress, with jaundice and a protuberant abdomen consistent with ascites. The patient was afebrile (98.2°F), heart rate of 79 beats per minute, blood pressure of 105/61 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 93% on room air. She had multiple large stellate lesions of retiform purpura with central hemorrhagic necrosis on both thighs, with surrounding induration (Figures 1 and 2). These purpuric plaques and perilesional skin were exquisitely painful to palpation.

Nonuremic calciphylaxis triggered by rapid weight loss and hypotension

Calciphylaxis is a potentially fatal disease caused by metastatic calcification of the small- and medium-sized blood vessels of the dermis and subcutis. It most commonly is seen in patients with renal disease requiring dialysis, but it also may be triggered by nonuremic causes in patients with known risk factors for calciphylaxis. We report a case of nonuremic calciphylaxis (NUC) occurring in the setting of multiple risk factors, including chronic corticosteroid use, obesity, rapid weight loss, and hypotension. A review of the literature also is provided with an in-depth discussion of the known risk factors and triggers of NUC.

[What's new in clinical dermatology?]

In this article, we performed a review of all new data of clinical relevance for the dermatologists that were published in the medical literature between September, 2017 and September, 2018. Besides advances that will be useful in day-to-day dermatological practice, we intended to give a more general perspective to this review by taking into account certain international health issues that might in final concern each of us in a globalized world. Focus were more particularly done on the following topics: infectious diseases (including sexually transmitted infections), neglected tropical diseases, adverse effects of drugs, bullous diseases, allergology, wound healing, dermatology on black skin, and public health dermatology.

Non-uremic calciphylaxis in a patient with multiple rheumatologic diseases

Non-uremic calciphylaxis is a rare, life-threatening condition characterized clinically by cutaneous necrosis and histologically by calcium deposition in small vessel walls. The etiology of non-uremic calciphylaxis remains the subject of ongoing speculation and debate. Herein we present a patient with calciphylaxis who had normal kidney function and numerous rheumatologic diseases, namely systemic lupus erythematosus (SLE), Sjogren syndrome (SS), and myasthenia gravis (MG). We review the pathophysiology, possible mechanisms, and management for non-uremic calciphylaxis.

Glans penis necrosis caused by calcific uremic arteriolopathy

Calcific uremic arteriolopathy (CUA) or calciphylaxis is a syndrome characterized by calcification of vessels located in the dermis and adipose tissue. It commonly occurs in patients with diabetes mellitus, hypertension, and end-stage renal disease. Clinical presentation generally begins with severe pain, followed by the presence of liveloid or purpuric plaques. Later the formation necrotic ulcers occur. This condition is associated with a poor prognosis, with a high rate of mortality within months of the diagnosis. Penile involvement is an uncommon but severe manifestation. We present an 81-year-old man with a history of diabetes mellitus, hypertension, and end-stage renal disease with a one-month evolution of painful necrotic ulcers on his glans penis. He was diagnosed with CUA. Owing to infection complicated by sepsis; penectomy was performed. Unfortunately, the patient died of myocardial infarction during his hospitalization.

Review: update on the management of calciphylaxis

Calciphylaxis is a disease of significant morbidity and mortality, predominantly affecting dialysis patients. The term 'calciphylaxis' was coined by Seyle et al. in 1961 to describe calcium deposition in the skin and subcutaneous soft tissue of uremic rats in response to 'triggers' (e.g. trauma, metallic salts) after exposure to 'sensitizing agents' (e.g. vitamin D and parathyroid hormone). In humans, calciphylaxis, however, is not a disorder of induced hypersensitivity. Instead, it is a disorder of cutaneous microvascular occlusion caused by thrombosis and calcification. Progressive, excruciatingly painful, non-healing wounds develop in these patients, pre-disposing them to high risk of sepsis and death. Calciphylaxis has no approved therapies. Increased awareness and research in this field have facilitated identification of risk factors and causation pathways. Development of therapeutic options and wound care management, however, are still at a nascent stage. Certain therapies have shown a promise that needs evaluation in prospective clinical trials. It is hoped that ongoing research will help us better understand the pathogenesis of this complex disease and develop efficacious treatment options. In this review, we outline the components involved in calciphylaxis diagnosis and treatment.

Calciphylaxis in a renal transplant recipient with normal graft function: A case report and review of literature

Calciphylaxis, also known as calcific uremic arteriolopathy, is a rare, life-threatening complication of end-stage renal disease. However, it may also occur in patients without renal failure, the nonuremic calciphylaxis. Most patients present with painful skin ulcers. Delayed diagnosis can lead to sepsis-related morbidity and mortality. Aberrations in calcium, phosphate, and parathyroid hormone physiology are common and biopsy is diagnostic. Early diagnosis and correction of vascular and metabolic aberrations may assist in healing as may the use of sodium thiosulfate and hyperbaric oxygen therapy. We report on successful treatment of a case of calciphylaxis in a renal transplant recipient with normal allograft function.

Update on calciphylaxis etiopathogenesis, diagnosis, and management

Calciphylaxis is a rare painful skin condition classically seen in patients with end-stage renal disease (ESRD), particularly those on chronic dialysis; however, it also has been increasingly reported in patients with normal renal function. Calciphylaxis is associated with high mortality rates, and excruciating pain and nonhealing ulcers often lead to recurrent hospitalizations and infectious complications. It is critical for dermatologists to recognize the clinical features of calciphylaxis to ensure accurate and timely diagnosis and proper management. In this article, we provide an update on calciphylaxis etiopathogenesis, diagnosis, and management, and we highlight the challenges faced in managing this potentially fatal condition.

[Early diagnosis, prevention and treatment for calcific uremic arteriolopathy]

Calcific uremic arteriopathy (CUA), termed calciphylaxis, is a rare but highly fatal clinical syndrome. There is no clearly laboratory diagnostic criteria for CUA. The medium and small arterial calcification and microthrombosis discovered by skin biopsy, radiologic imaging，bone scan and the evidence of activation of the bone morphogenetic protein signal (BMPs) transduction pathway are useful for early diagnosis of this disease. The common therapies (including intravenous sodium thiosulfate (STS) and bisphosphonates, hyperbaric oxygen therapy and other symptomatic supports) are used for the management of wounds, pain, nutrition, dialysis and so on. Controlling the chronic kidney disease-mineral and bone disorder (CKD-MBD) and some complications of dialysis and drugs (such as warfarin, active vitamin D) can prevent CUA. However, CUA patients still have poor prognosis and high mortality. Since some patients progress rapidly, it is of great importance to make early diagnosis and provide effective treatments with multidisciplinary management.

A case report of pediatric calciphylaxis-a rare and potentially fatal under diagnosed condition

RATIONALE

Though to be rare, calcific uremic arteriolophathy (CUA) is an ectopic calcification entity causing pain and disabilities in patients with chronic renal insufficiency, thus increasing the morbidity and mortality.

PATIENT CONCERN

We report a case of four years old boy admitted with acute respiratory failure. Physical examination revealed: irritability, purple subcutaneous hard nodules, tachypnea, dry spasmodic cough, respiratory rate 45/min, heart rate 110/min, blood pressure 100/60 mmHg, with normal heart sounds, no murmurs, hepatomegaly with hepato-jugular reflux. He was diagnosed at 2 years old with stage 5 chronic kidney disease due to untreated posterior urethral valve, and subsequently started peritoneal dialysis. He developed severe renal osteodystrophy, refractory to standard phosphate binders.

DIAGNOSES

Pathology examination revealed the presence of diffuse calcifications involving the skin, brain, heart, lung, kidney, stomach and pancreas, consistent with the underlying diagnosis of CUA.

INTERVENTION

Apart from standard treatment for end stage renal disease and associated co-morbidities, intensive care procedures have been initiated: oxygen therapy, continuous positive airway pressure, inotropic medication (Dopamine, Dobutamine), anticonvulsants (Diazepam), and antiedematous therapy (Dexamethasone).

OUTCOME

His pulmonary function rapidly deteriorated up to the severe hypoxemia, seizures and cardio-respiratory arrest, despite the initiation of intensive care measures.

LESSONS

A careful follow up of small children might detect in time an abnormal urinary pattern. The diagnosis of growth failure should also trigger urgent further investigation.

[Calcific uremic arteriolopathy (calciphylaxis) : update in 2018]

Calciphylaxis is a rare disease with a poor prognostic that mostly occurs in patients with renal failure. Diagnosis is difficult and skin biopsy is the gold standard diagnostic procedure, although it may aggravate skin lesions. Identification of the typical cutaneous signs is important to initiate adequate medical care. Several differential diagnoses must be excluded. Treatments should include appropriate pain management, local wound pain, daily dialysis, intravenous sodium thiosulfate treatment, hyperbaric oxygenotherapy, thigh control of calcium-phosphate metabolism and interruption of medications that could contribute to calciphylaxis. Palliative care should be considered in uncontrolled clinical course.