A case study, calciphylaxis: an exercise in human caring

Caring for a patient with calciphylaxis is challenging emotionally and clinically. The case of a young woman with the disease is related.

[Calcific uremic arteriolopathy (calciphylaxis)]

We present the case of a end stage renal failure patient treated with haemodialysis who developed painful nodules of the subcutis which progressed to ulcerative and necrotic lesions, gradually spreading. The diagnosis of calcific uremic arteriolopathy was made, based on histologic findings showing adipose tissue with necrotic areas and calcifications of the arterioles's media. We describe the clinical presentation of this syndrome which is associated with a high mortality and resume the actual conceptions about the pathogenesis, the diagnosis, prevention and treatment.

Calciphylaxis of the breast: a rare disease in the differential diagnosis of breast cancer

Calciphylaxis is a rare, but potentially life-threatening condition usually observed in patients with end-stage chronic renal disease and characterized by small- and medium-sized blood vessel calcification leading to tissue ischemia. The clinical features are primarily cutaneous, consisting of skin necrosis and ulceration, mostly located in the lower extremities. We report a case of a 56-year-old woman with a previous history of renal disease and atypical lobular hyperplasia of the right breast, who developed painful skin necrosis on both breasts. Differential diagnosis comprises acute bacterial infection with ulceration, cutaneous vasculitis, cancer and calciphylaxis.

Calciphylaxis Mimicking Inflammatory Breast Cancer

Calciphylaxis is a rare disorder characterized by microcalcification of small- and medium-sized blood vessels causing cutaneous and soft tissue necrosis. Patients usually present with painful, violaceous skin discoloration in a livedo reticularis pattern. We present a case of a 59-year-old woman with end-stage renal disease (ESRD) who manifested signs and symptoms of inflammatory breast cancer. The patient underwent an open biopsy and subsequent mastectomy, with final pathology results of calciphylaxis. Due to recurrent hyperparathyroidism, she underwent a re-parathyroidectomy with reimplantation. To our knowledge, this is the first reported case of calciphylaxis recurrence after subtotal parathyroidectomy. We propose that those patients with ESRD who develop breast pathology consistent with inflammation and necrosis, and have no malignancy, be evaluated for secondary hyperparathyroidism. Total parathyroidectomy with reimplantation should be performed. Mastectomy should be performed for unresolving symptoms, necrosis or infection.

Calciphylaxis: calcific uraemic arteriolopathy--a case study

Having worked in nephrology for more than 20 years, and never encountering this condition before, we came across three patients who had been diagnosed with calciphylaxis in the space of 12 months. This condition is also known as calcific uraemic arteriolopathy and is a syndrome of medical calcification of the small arteries, which leads to painful ischaemia of the surrounding subcubitis and skin (1). Prevalence of 1-4% has been estimated in various haemodialysis populations. Also 1% per year in dialysis patients has also been suggested (3). The mortality rate for distal lesions is 23%, whilst the mortality for proximal lesions is 63% (4). The pathogenesis of this condition remains uncertain. However, vascular calcium deposition is thought to be important, and raised serum phosphate levels were associated with a substantially increased risk of calciphylaxis. Although PTH levels were high, plasma PTH was not consistently higher in patients with calciphylaxis than controls (5). The important aspect of the condition for the patients is the sheer pain and distress suffered, as well as the high mortality rate. Therefore, the implications for nurses are early detection, to allow speedy treatment to take place and involvement of the multidisciplinary team to enhance care and provide as much support as possible, thus facilitating optimal outcome and comfort.

Calcific uremic arteriolopathy: advances in pathogenesis and treatment

Calcific uremic arteriolopathy (CUA) is a rare but serious life-threatening complication of CRF that manifests as painful nonhealing eschars in association with panniculitis and dermal necrosis. This condition is being increasingly recognized and reported as a contributing factor to death in dialysis patients. The pathognomic lesion is vascular calcification with intimal arterial hypertrophy and superimposed small vessel thrombosis. Hyperparathyroidism and elevated concentrations of serum phosphate remain consistent clinical features of most cases reported. Controversy still exists regarding the role of parathyroidectomy in this condition with some studies suggesting improved outcome with surgical intervention. A number of potential new etiological factors have been identified including reduced serum levels of a calcification inhibitory protein alpha,2-Heremans-Schmid glycoprotein (Fetuin-A) and abnormalities in smooth muscle cell biology in uremia. Promising new treatment options including hyperbaric oxygen therapy and sodium thiosulfate infusion have been reported in case series. Benefits from biphosphonates and tissue plasminogen activator have also been reported. Overall these new treatment approaches and understanding of potential mechanisms underlying this important severe clinical condition offer new hope in the diagnosis and management of this severely morbid and often fatal condition.

Calciphylaxis and bone scintigraphy: case report with histological confirmation and review of the literature

We present a patient with a history of end-stage renal disease, who developed skin lesions in the bilateral calves a month after the initiation of hemodialysis. The lesions were biopsied, and the histological findings were consistent with a diagnosis of calciphylaxis. The patient had a baseline pretreatment bone scan that showed extensive systemic disease. The patient died 20 days after the imaging study. A review of the literature on bone scans and calciphylaxis is presented.

[Vascular emergencies in dermatology]

Life-threatening vascular complications of the skin are rare and usually reflect underlying systemic diseases. Lesions are sudden in onset, become necrotic and may be severe or life-threatening. Effective management requires an understanding of the underlying medical condition, such as arterial thrombosis, temporal arteritis, calciphylaxis and purpura fulminans. In contrast, the acute painful symptoms of erythromelalgia often lead to an urgent dermatologic consultation but pose no acute risk.

Calciphylaxis: emerging concept in vascular patients

Calciphylaxis is a small vessel vasculopathy with medial calcification associated with intimal proliferation, fibrosis and thrombosis. This study discusses the clinical features and treatment of calciphylaxis and assesses the prognosis of patients with calciphylaxis. All patients admitted to vascular or renal wards from January 2003 to December 2004 at Royal Perth Hospital, with diagnosis of calciphylaxis confirmed histologically were included in the study. Five patients were included in the study; four male and one female. Three patients had end stage renal failure on haemodialysis and two had normal renal function. All three patients with end-stage renal failure had secondary hyperparathyroidism associated with elevated parathormone and corrected ionised calcium. The two patients with normal renal function had normal calcium, phosphate, and parathormone levels. The diagnosis of calciphylaxis was confirmed in all patients. The wounds of four patients healed and one patient died 8 months after the diagnosis of calciphylaxis had been made. Calciphylaxis is a condition mostly present in patients with end-stage renal failure and can occur in patients with normal renal function. It usually carries a poor prognosis, but in this small series the outcome of patients was good with satisfactory healing of wounds.

Calciphylaxis with a protracted course in a patient with end-stage renal failure

Calciphylaxis is a rare condition with a high mortality involving mural calcification of small vessels and occurring primarily in patients with end-stage renal disease. Most cases are characterized by rapid progression of tender subcutaneous nodules or cutaneous plaques to epidermal necrosis, with death in the majority of cases occurring from sepsis. The condition is still poorly understood and the pathogenesis not known. We report a case of calciphylaxis following an unusually benign course. Our patient was a 63-year-old Chinese woman with end-stage renal failure undergoing peritoneal dialysis who presented with itchy pruriginous rashes on her limbs and trunk with subsequent development of eschars and ulceration. Biopsy confirmed the presence of calcification within vessel walls in the subcutis. She was managed conservatively and refused a parathyroidectomy. Surprisingly, her disease did not worsen but remained stable. She died from an acute myocardial infarction 5 months after presenting to our clinic.

Gastric calciphylaxis in a patient with a functioning renal allograft

Calciphylaxis or calcific uremic arteriolopathy (CUA), not uncommon in the dialysis population, has also been reported in renal transplant recipients with varying stages of renal dysfunction. While cutaneous involvement in both populations is the most common feature, visceral involvement is rarely described. We report a patient with a long-standing functioning renal allograft who presented with visceral calciphylaxis in a Dieulafoy lesion requiring gastrectomy. Histopathology revealed typical features of CUA. The current literature describing CUA in post-transplant patients is reviewed.

[Calcific uraemic arteriolopathy (calciphylaxis): incidence, clinical features and long term outcomes]

Calcific uraemic arteriolopathy, also named calciphylaxis, is a rare but serious disorder characterized by medial mural calcification of small vessel leading to tissue ischaemia. It most commonly occurs in end stage renal disease patients on dialysis or recently received renal transplant with chronic nephropathy allograft. The pathogenesis of calciphylaxis is poorly understood. Abnormalities in mineral metabolism are clearly involved, but the specific factors that induces this disorder are not completely known.

OBJECTIVES

Describe the main clinical features, outcomes and follow up of all calciphylaxis cases recorded in our dialysis unit in order to analyse the incidence, the main biologic parameters and the therapeutic background in which calciphylaxis appeared.

MATERIAL AND METHODS

We performed a descriptive study about all the calciphylaxis cases diagnosed at our dialysis unit between the years 1991 and 2005.

RESULTS

8 cases, 6 women. Mean age: 65.3 years. All the patients were on haemodialysis treatment (one previous renal transplant). Mean time on dialysis was 76.6 months. Cumulative incidence was 1.17%. The principal end stage renal disease aethiology was neprhoangioeslerosis in four patients. Secondary hiperparatyrhoidism was present in 4 patients and 2 of them had been paratyrhoidectomized previously. A second cutaneous biopsy was needed for correct diagnosis in 3 patients. Calciphylaxis distal lesions were present in 7 patients. Two cases required urgent paratyrhoidectomy in order to control calciphylaxis. Only in 2 cases a Ca x P product > 60 mg/dL was present and 3 cases had PTHi values higher than 300 pg/mL. Calcium phosphate binders and vitamin D were present in 2 and 4 cases, respectively. One patient with proximal calciphylaxis died due to skin injury infection.

CONCLUSIONS

Calciphylaxis is a rare disorder but not exceptional, related to end stage renal disease patients. The diagnosis requires a high clinical suspicion, being sometimes difficult to distinguish from other entities in spite of pathological study. Proximal distribution of calciphylaxis had worst prognostic. Metabolic disorders and therapeutics background were not different from other patients included in dialysis treatment.

Penile necrosis by calciphylaxis in a diabetic patient with chronic renal failure

The patient was a 41-year-old man who had suffered from diabetes for 24 years and had been on insulin therapy for 17 years. The patient had commenced hemodialysis in 1999. Some of his toes on both feet had been amputated in 2000 due to diabetic gangrene. The patient was admitted to our hospital in early March 2005 complaining of a painful ulcer on the tip of the penis. At the time of admission, multiple ulcers and necrosis were observed on the prepuce and penis, as well as an ulcer on the left foot and gangrene of the left great toe. Imaging studies demonstrated severe arteriosclerosis with calcification of both large and small arteries. After penile amputation was performed because of severe pain, the wound became ulcerated, and a rectal ulcer as well as skin ulcers also developed in the bilateral inguinal regions. The penile necrosis, skin ulcers, and rectal ulcer were thought to have been caused by calciphylaxis. Calciphylaxis is a disorder in which necrosis occurs at sites of arterial obstruction and calcification, and the prognosis is poor. Seventeen patients with penile necrosis due to calciphyalxis, including our patient, have been reported in Japan. They all had a long history of diabetes, and 15 of the 17 patients were on dialysis.