Affiliations
Department of Pathology, Medical Center, George Washington University, Washington, District of Columbia
Given name(s)
Oliver
Family name
Szeto
Degrees
MD, MBA

Lower Extremity Ulcers

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Mon, 01/02/2017 - 19:34
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Lower extremity ulcers and the satisfied search

A 62‐year‐old man with hypertension, diabetes mellitus, and coronary artery disease (CAD), on peritoneal dialysis, presented with a nonhealing left lower extremity ulcer (Figure 1). Treatment with empiric antibiotics showed no improvement and cultures remained persistently negative. A surgical specimen revealed pathological changes consistent with calciphylaxis (Figures 2 and 3).

Figure 1
A 3‐cm × 5‐cm lesion on the lateral portion of the distal left lower extremity with surrounding erythema and eschar.
Figure 2
Histopathological specimen showing epidermal ulceration (white arrowhead), dermal fibrosis (black arrowhead), arterial mural calcification (white arrow), and arterial thrombosis (black arrow).
Figure 3
Calcification (white arrowhead) and thrombosis (black arrow) of small‐sized to medium‐sized hypodermic arterioles in a background of fat necrosis and septal panniculitis (black arrowhead), consistent with calciphylaxis.

With a mortality between 30% and 80% and a 5‐year survival of 40%,1‐3 calciphylaxis, or calcific uremic arteriolopathy, is devastating. Dialysis and a calcium‐phosphate product above 60 mg2/dL2 increased the index of suspicion (our patient = 70).4 As visual findings may resemble vasculitis or atherosclerotic vascular lesions, biopsy remains the mainstay of diagnosis. Findings include intimal fibrosis, medial calcification, panniculitis, and fat necrosis.5

Management involves aggressive phosphate binding, preventing superinfection, and surgical debridement.6 The evidence for newer therapies (sodium thiosulfate, cinacalcet) appears promising,7‐10 while the benefit of parathyroidectomy is equivocal.11 Despite therapy, our patient developed new lesions (right lower extremity, penis) and opted for hospice services.

References
  1. Andreoli TE,Carpenter CCJ,Griggs RC,Loscalzo J.Cecil Essentials of Medicine.6th ed.New York:W.B. Saunders;2003.
  2. Worth RL.Calciphylaxis: pathogenesis and therapy.J Cutan Med Surg.1998;2(4):245248.
  3. Trent JT,Kirsner RS.Calciphylaxis: diagnosis and treatment.Adv Skin Wound Care.2001;14(6):309312.
  4. Mathur RV,Shortland JR,el‐Nahas AM.Calciphylaxis.Postgrad Med J.2001;77(911):557561.
  5. Silverberg SG, DeLellis RA, Frable WJ, LiVolsi VA, Wick MR, eds.Silverberg's Principles and Practice of Surgical Pathology and Cytopathology. Vol.1‐2.4th ed.Philadelphia:Elsevier Churchill Livingstone;2006.
  6. Naik BJ,Lynch DJ,Slavcheva EG,Beissner RS.Calciphylaxis: medical and surgical management of chronic extensive wounds in a renal dialysis population.Plast Reconstr Surg.2004;113(1):304312.
  7. Block GA,Martin KJ,de Francisco AL, et al.Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis.N Engl J Med.2004;350(15):15161525.
  8. Guerra G,Shah RC,Ross EA.Rapid resolution of calciphylaxis with intravenous sodium thiosulfate and continuous venovenous haemofiltration using low calcium replacement fluid: case report.Nephrol Dial Transplant.2005;20(6):12601262.
  9. Cicone JS,Petronis JB,Embert CD,Spector DA.Successful treatment of calciphylaxis with intravenous sodium thiosulfate.Am J Kidney Dis.2004;43(6):11041108.
  10. Mataic D,Bastani B.Intraperitoneal sodium thiosulfate for the treatment of calciphylaxis.Ren Fail.2006;28(4):361363.
  11. Arch‐Ferrer JE,Beenken SW,Rue LW,Bland KI,Diethelm AG.Therapy for calciphylaxis: an outcome analysis.Surgery.2003;134(6):941944; discussion 944‐945.
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A 62‐year‐old man with hypertension, diabetes mellitus, and coronary artery disease (CAD), on peritoneal dialysis, presented with a nonhealing left lower extremity ulcer (Figure 1). Treatment with empiric antibiotics showed no improvement and cultures remained persistently negative. A surgical specimen revealed pathological changes consistent with calciphylaxis (Figures 2 and 3).

Figure 1
A 3‐cm × 5‐cm lesion on the lateral portion of the distal left lower extremity with surrounding erythema and eschar.
Figure 2
Histopathological specimen showing epidermal ulceration (white arrowhead), dermal fibrosis (black arrowhead), arterial mural calcification (white arrow), and arterial thrombosis (black arrow).
Figure 3
Calcification (white arrowhead) and thrombosis (black arrow) of small‐sized to medium‐sized hypodermic arterioles in a background of fat necrosis and septal panniculitis (black arrowhead), consistent with calciphylaxis.

With a mortality between 30% and 80% and a 5‐year survival of 40%,1‐3 calciphylaxis, or calcific uremic arteriolopathy, is devastating. Dialysis and a calcium‐phosphate product above 60 mg2/dL2 increased the index of suspicion (our patient = 70).4 As visual findings may resemble vasculitis or atherosclerotic vascular lesions, biopsy remains the mainstay of diagnosis. Findings include intimal fibrosis, medial calcification, panniculitis, and fat necrosis.5

Management involves aggressive phosphate binding, preventing superinfection, and surgical debridement.6 The evidence for newer therapies (sodium thiosulfate, cinacalcet) appears promising,7‐10 while the benefit of parathyroidectomy is equivocal.11 Despite therapy, our patient developed new lesions (right lower extremity, penis) and opted for hospice services.

A 62‐year‐old man with hypertension, diabetes mellitus, and coronary artery disease (CAD), on peritoneal dialysis, presented with a nonhealing left lower extremity ulcer (Figure 1). Treatment with empiric antibiotics showed no improvement and cultures remained persistently negative. A surgical specimen revealed pathological changes consistent with calciphylaxis (Figures 2 and 3).

Figure 1
A 3‐cm × 5‐cm lesion on the lateral portion of the distal left lower extremity with surrounding erythema and eschar.
Figure 2
Histopathological specimen showing epidermal ulceration (white arrowhead), dermal fibrosis (black arrowhead), arterial mural calcification (white arrow), and arterial thrombosis (black arrow).
Figure 3
Calcification (white arrowhead) and thrombosis (black arrow) of small‐sized to medium‐sized hypodermic arterioles in a background of fat necrosis and septal panniculitis (black arrowhead), consistent with calciphylaxis.

With a mortality between 30% and 80% and a 5‐year survival of 40%,1‐3 calciphylaxis, or calcific uremic arteriolopathy, is devastating. Dialysis and a calcium‐phosphate product above 60 mg2/dL2 increased the index of suspicion (our patient = 70).4 As visual findings may resemble vasculitis or atherosclerotic vascular lesions, biopsy remains the mainstay of diagnosis. Findings include intimal fibrosis, medial calcification, panniculitis, and fat necrosis.5

Management involves aggressive phosphate binding, preventing superinfection, and surgical debridement.6 The evidence for newer therapies (sodium thiosulfate, cinacalcet) appears promising,7‐10 while the benefit of parathyroidectomy is equivocal.11 Despite therapy, our patient developed new lesions (right lower extremity, penis) and opted for hospice services.

References
  1. Andreoli TE,Carpenter CCJ,Griggs RC,Loscalzo J.Cecil Essentials of Medicine.6th ed.New York:W.B. Saunders;2003.
  2. Worth RL.Calciphylaxis: pathogenesis and therapy.J Cutan Med Surg.1998;2(4):245248.
  3. Trent JT,Kirsner RS.Calciphylaxis: diagnosis and treatment.Adv Skin Wound Care.2001;14(6):309312.
  4. Mathur RV,Shortland JR,el‐Nahas AM.Calciphylaxis.Postgrad Med J.2001;77(911):557561.
  5. Silverberg SG, DeLellis RA, Frable WJ, LiVolsi VA, Wick MR, eds.Silverberg's Principles and Practice of Surgical Pathology and Cytopathology. Vol.1‐2.4th ed.Philadelphia:Elsevier Churchill Livingstone;2006.
  6. Naik BJ,Lynch DJ,Slavcheva EG,Beissner RS.Calciphylaxis: medical and surgical management of chronic extensive wounds in a renal dialysis population.Plast Reconstr Surg.2004;113(1):304312.
  7. Block GA,Martin KJ,de Francisco AL, et al.Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis.N Engl J Med.2004;350(15):15161525.
  8. Guerra G,Shah RC,Ross EA.Rapid resolution of calciphylaxis with intravenous sodium thiosulfate and continuous venovenous haemofiltration using low calcium replacement fluid: case report.Nephrol Dial Transplant.2005;20(6):12601262.
  9. Cicone JS,Petronis JB,Embert CD,Spector DA.Successful treatment of calciphylaxis with intravenous sodium thiosulfate.Am J Kidney Dis.2004;43(6):11041108.
  10. Mataic D,Bastani B.Intraperitoneal sodium thiosulfate for the treatment of calciphylaxis.Ren Fail.2006;28(4):361363.
  11. Arch‐Ferrer JE,Beenken SW,Rue LW,Bland KI,Diethelm AG.Therapy for calciphylaxis: an outcome analysis.Surgery.2003;134(6):941944; discussion 944‐945.
References
  1. Andreoli TE,Carpenter CCJ,Griggs RC,Loscalzo J.Cecil Essentials of Medicine.6th ed.New York:W.B. Saunders;2003.
  2. Worth RL.Calciphylaxis: pathogenesis and therapy.J Cutan Med Surg.1998;2(4):245248.
  3. Trent JT,Kirsner RS.Calciphylaxis: diagnosis and treatment.Adv Skin Wound Care.2001;14(6):309312.
  4. Mathur RV,Shortland JR,el‐Nahas AM.Calciphylaxis.Postgrad Med J.2001;77(911):557561.
  5. Silverberg SG, DeLellis RA, Frable WJ, LiVolsi VA, Wick MR, eds.Silverberg's Principles and Practice of Surgical Pathology and Cytopathology. Vol.1‐2.4th ed.Philadelphia:Elsevier Churchill Livingstone;2006.
  6. Naik BJ,Lynch DJ,Slavcheva EG,Beissner RS.Calciphylaxis: medical and surgical management of chronic extensive wounds in a renal dialysis population.Plast Reconstr Surg.2004;113(1):304312.
  7. Block GA,Martin KJ,de Francisco AL, et al.Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis.N Engl J Med.2004;350(15):15161525.
  8. Guerra G,Shah RC,Ross EA.Rapid resolution of calciphylaxis with intravenous sodium thiosulfate and continuous venovenous haemofiltration using low calcium replacement fluid: case report.Nephrol Dial Transplant.2005;20(6):12601262.
  9. Cicone JS,Petronis JB,Embert CD,Spector DA.Successful treatment of calciphylaxis with intravenous sodium thiosulfate.Am J Kidney Dis.2004;43(6):11041108.
  10. Mataic D,Bastani B.Intraperitoneal sodium thiosulfate for the treatment of calciphylaxis.Ren Fail.2006;28(4):361363.
  11. Arch‐Ferrer JE,Beenken SW,Rue LW,Bland KI,Diethelm AG.Therapy for calciphylaxis: an outcome analysis.Surgery.2003;134(6):941944; discussion 944‐945.
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Journal of Hospital Medicine - 5(3)
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Journal of Hospital Medicine - 5(3)
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E31-E32
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E31-E32
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Lower extremity ulcers and the satisfied search
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