Atypical calciphylaxis in a patient receiving warfarin then resolving with cessation of warfarin and application of hyperbaric oxygen therapy

Calciphylaxis is a rare, usually fatal vasculopathic disorder characterized by cutaneous ischemia and necrosis due to calcification of arterioles. Although calciphylaxis is most frequently associated with end-stage renal disease (ESRD) and secondary hyperparathyroidism, it has been reported infrequently among patients on warfarin. No standard treatment has been established for atypical calciphylaxis; however, a potentially beneficial treatment is hyperbaric oxygen therapy (HBOT). A high degree of clinical suspicion, early diagnosis, and understanding the pathophysiology of this disease promotes the optimal management of this extremely morbid and often fatal condition.

CASE REPORT

We present a 63-year-old Polynesian woman with biopsy-proven calciphylaxis in the absence of ESRD or elevated serum calcium levels while taking warfarin. Therapeutic dose enoxaparin was substituted for warfarin and she received 40 sessions of HBOT during which lower extremity ulcers resolved.

DISCUSSION

Warfarin has been implicated when calciphylaxis presents in an atypical fashion. No guidelines exist for treatment of atypical calciphylaxis in the setting of concomitant warfarin therapy. Up to 80% of calciphylaxis patients die within 1 year of diagnosis. Our patient was changed to low-molecular-weight heparin and received HBOT.

CONCLUSION

We present what we believe is the first case of atypical calciphylaxis thought to be attributable to warfarin treated with a therapeutic substitution of anticoagulant and HBOT leading to resolution of cutaneous lesions.

[Calciphylaxis and penile necrosis: a case report and review of the literature ]

INTRODUCTION

Calciphylaxis is a rare clinic condition characterised by skin necrosis due to medial and intimal calcification of small and medium arteries. It's observed in patients affected by end stage renal disease associated to secondary hyperparathyroidism. Penile involvement has been documented in very few cases. We present both a case of penile calciphylaxis and a review of literature, in order to increase comprehension of pathophysiology, diagnosis and therapy of this rare disease.

MATERIALS AND METHODS

A retrospective review of literature was performed after treating a case of penile calciphylaxis. We describe patient characteristics, clinical presentation, laboratory and histo-pathologic findings, therapeutic strategy and outcomes of the case.

RESULTS

A 65 year-old man, affected by diabetes, chronic ischemic cardiopathy and chronic renal failure in hemodialytic treatment, was referred to our unit for the presence of increased consistency and significative pain of the distal portion of penis evolving in a complete glans necrosis. Blood levels of parathormone (PTH), calcium (Ca) and phosphorous (P) resulted pathologically elevated, promoting tissutal calcium deposition. The patient was treated with partial penectomy and the histologic findings confirm diagnosis of calciphylaxis, showing an ulcerative necrosis of glans with extensive calcium deposition and luminal narrowing of penile small arteries.

CONCLUSIONS

The increase of number of patients with chronic renal failure in hemodialytic treatment could make penile calciphylaxis more prevalent in the future. Early diagnosis, lowering of pathologic blood levels of Ca and P associated to surgical treatment of necrotic lesions of the patient could be fundamental for a better prognosis of this aggressive disease.

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.