Necrotic Skin Lesions

Whats Wrong With This Picture? Woman With Painful Necrotic Skin Lesions


Figure 1
Figure 1
Figure 2
Figure 2

A 54-year-old white woman presents with extremely tender, firm lesions on the right hip and legs that have been increasing in size and number over the past few months.

History. The patient has hypertension, non–insulin-dependent type 2 diabetes mellitus, and end-stage renal disease, for which she has been receiving hemodialysis via a 2-way catheter in the right internal jugular vein. She also has multiple superficial skin abscesses.

Examination. Cardiac, pulmonary, abdominal, and neurologic findings are normal. Multiple necrotic ulcerations of various sizes (which are shown here on the right upper thigh) are noted on the right hip and lower extremities.

Laboratory studies. Blood urea nitrogen level is 64 mg/dL; serum creatinine, 7.5 mg/dL; total calcium, 8.3 mg/dL; ionized calcium, 1.11 mg/dL; parathyroid hormone, 172 pg/mL; phosphorus, 6.7 mg/dL; and albumin, 2.2 g/dL. White blood cell count is 12,700/μL, with 87% granulocytes. Hemoglobin level, 10.3 g/dL; hematocrit, 33%; and platelet count, 407,000/μL.

Biopsy of one of the ulcerations is performed, and a specimen is stained with hematoxylin-eosin for histopathologic examination.

To which of the following conditions do the biopsy specimen, the history, and physical and laboratory findings point?

A. Calciphylaxis B. Pyoderma gangrenosum C. Vibrio vulnificus infection D. Necrobiosis lipoidica with ulceration E.Lupus panniculitis


Calciphylaxis is a rare but serious disorder characterized by systemic medial calcification of the arteries and tissue ischemia.1,2 It most commonly occurs in patients with end-stage renal disease who are receiving dialysis or who recently underwent renal transplantation.1-5 However, a similar syndrome may be seen infrequently with any cause of hypercalcemia, including primary hyperparathyroidism, vitamin D intoxication, the milk-alkali syndrome, idiopathic neonatal hypercalcemia, and various hematologic and solid organ malignancies.