A 70 year old Caucasian women is admitted with a 2 week history of extremely painful large violaceous, indurated plaques on her inner thighs bilaterally. She has a past medical history of hypertension, diabetes mellitus, and chronic kidney disease not on dialysis, peripheral arterial disease, hypothyroidism and rheumatoid arthritis. Five months prior she initially noted pale erythematous non painful lesions in the same area which have progressed to dark colored extremely painful ulcerating lesions in the last month. She is experiencing severe pain in her thighs and legs due to these lesions with intensity10/10 that has impaired her walking to the point that she is bedbound. Review of systems is negative for other complaints. She denies fever or chills.
Physical examination reveals a thin well appearing women in mild distress due to pain. Skin examination reveals large necrotic ulcerated plaques with surrounding erythematous patches in medial thighs bilaterally and smaller similar lesions in lateral thighs and calfs bilaterally. Remaining physical examination is unremarkable. Labs were significant for leukocytosis of 14.6, an elevated Cr of 1.6 and BUN of 41. The blood calcium and phosphorus levels were normal at 8.9 and the 3.4 respectively. She underwent skin biopsy which with calcification within vessel walls and lumen in the deep dermis and subcutaneous tissue and interstitial calcification. There was also fat necrosis and fibrinoid degeneration of some of the vessel walls with thrombosis. This was consistent with calcipylaxis and she was treated thiosulfate with improvement of symptoms. Her hospital course was complicated by fevers and blood cultures positive for MRSA requiring treatment with daptomycin.
Calcyphilaxis is characterized by medial calcification of arterioles and thrombotic vaso‐occlusion leading to ischemia and subcutaneous necrosis. It is most commonly seen in patients with ESRD on hemodialysis but can occur in non‐ESRD patients who have CKD. It occurs rarely in patients with normal GFR and has been associated with autoimmune disease, malignancy, primary hyperthyroidism and warfarin use. The skin lesions develop on areas with greatest adiposity, including abdomen and thigh and are excruciatingly painful. The characteristic skin lesions are violaceous, painful, plaque–like subcutaneous nodules that progress to necrotic ulcers which often become superinfected. There are no specific laboratory findings although some patients may have elevated levels of PTH, phosphorous, calcium, and the calcium‐phosphorous products. Diagnosis is made by skin biopsy which reveals panniculitis, medial arteriolar calcification and arterial occlusion in the absence of vasculitic changes, although it may be falsely negative.
Calcyphilaxis should be considered in patients who present with violaceous skin lesions or non healing ulcers in areas of increased adiposity regardless of the presence of ESRD and hemodialysis.
To cite this abstract:Fialho A, Nguyen N, Orra S, Suri S. Painful Skin Leions in an Elderly Women. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 415. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/painful-skin-leions-in-an-elderly-women/. Accessed April 1, 2020.