Case Presentation: A 62 year-old man was admitted to the hospital with hypervolemia. His past medical history included chronic kidney disease stage V not on hemodialysis and type-2 diabetes mellitus. He reported bilateral lower extremity edema, shortness of breath, and poor urine output despite oral furosemide. Vital signs were temperature 97 degrees F, heart rate 74 per minute, respiratory rate 20 per minute, blood pressure 174/82mmHg, and oxygen saturation 99% on 5L O2. Physical exam revealed a chronically ill man with diminished breath sounds, pulmonary crackles, and 3+ lower extremity edema to the thighs. Blood urea nitrogen was 171mg/dL, creatinine 13.6mg/dL, calcium 7.1mg/dL, and phosphorus 8.6mg/dL. Hemodialysis was initiated. During his second session, he experienced sudden severe penile pain. He reported intermittent penile pain and pale discoloration of fingertips for one month. Examination revealed pallor and tenderness of the glans penis and distal penile shaft with proximal hyperemia without edema or drainage. There were no other skin lesions. CT angiography of the abdomen and pelvis revealed diffuse arterial atherosclerotic calcifications, including the small vessels of penis and perineum, without thrombosis. The patient was diagnosed with penile calciphylaxis. His arterial disease was not amenable to intervention. Penectomy was deferred in expectation of auto-amputation and due to his surgical risk. He was treated with analgesia, wound care, and sodium thiosulfate.
Discussion: Calciphylaxis, also called calcific uremic arteriopathy, occurs in end stage renal disease. Annual incidence is 35 cases per 10,000 hemodialysis patients in the United States. It is due to calcium deposition and occlusion of small arteries, causing painful necrotic ulcerations and eschars. It typically involves the lower extremities: penile involvement is rare. Penile calciphylaxis is accompanied by extragenital involvement in 67% of cases. Hyperphosphatemia, hypercalcemia, and diabetes are risk factors. Vascular calcifications on imaging support the diagnosis. Skin biopsy may be performed if clinical diagnosis is uncertain. Histopathology may show calcification, thrombosis, and fibrointimal hyperplasia of arteries and arterioles with ischemia and panniculitis. There are no approved therapies for calciphylaxis; optimal management is multidisciplinary, including pain control, wound care, nutritional support, hyperphosphatemia treatment, and sodium thiosulfate. One-year mortality is over 50%.
Conclusions: Penile calciphylaxis is an atypical presentation of calcific uremic arteriopathy, a life-threatening condition affecting dialysis patients. Our patient’s risk factors were chronic kidney disease, diabetes mellitus and hyperphosphatemia. He experienced subacute stuttering penile ischemic symptoms prior to onset of critical penile ischemia. This case illustrates the importance of thorough review of systems and dermatologic examination in patients with risk factors for calciphylaxis.
To cite this abstract:Shimada, M; Brown, CC; Harrington, M. PENILE CALCIPHYLAXIS ASSOCIATED WITH HEMODIALYSIS INITIATION. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 993. https://www.shmabstracts.com/abstract/penile-calciphylaxis-associated-with-hemodialysis-initiation/. Accessed February 24, 2020.