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Calciphylaxis with Normal Renal and Parathyroid Function Not As Rare As Previously Believed

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Calciphylaxis with Normal Renal and Parathyroid Function Not As Rare As Previously Believed OBSERVATION Calciphylaxis With Normal Renal and Parathyroid Function Not as Rare as Previously Believed Andrew H. Kalajian, MD; Paula S. Malhotra, MD; Jeffrey P. Callen, MD; Lynn P. Parker, MD Background: Calciphylaxis is a life-threatening form of previously reported cases of nontraditional calciphylaxis metastatic calcification-induced microvascular occlusion identified the following patient characteristics that high- syndrome. Although traditionally observed in patients with light clinical situations potentially predisposing to calci- end-stage renal disease and/or hyperparathyroidism, the phylaxis: hypoalbuminemia, malignant neoplasm, sys- development of calciphylaxis in “nontraditional” pa- temic corticosteroid use, anticoagulation with warfarin tients having both normal renal and parathyroid func- sodium or phenprocoumon, chemotherapy, systemic in- tion has been reported. However, to date there has been flammation, hepatic cirrhosis, protein C or S deficiency, no collective analysis identifying common patient char- obesity, rapid weight loss, and infection. acteristics potentially predisposing to the development of calciphylaxis in nontraditional patients. Conclusions: Calciphylaxis is becoming increasingly common in patients with normal renal and parathyroid Observations: A 58-year-old woman with endometrial function. The observations from this study may assist der- carcinoma developed extensive calciphylaxis despite the matologists in the rapid diagnosis and prompt initiation presence of normal renal and parathyroid function. The of therapy for this devastating disease. disease resolved with rapid diagnosis, supportive therapy, and medical management. Analysis of this case and the 13 Arch Dermatol. 2009;145(4):451-458 ALCIPHYLAXIS, ALSO KNOWN secondary hyperparathyroidism (re- as calcific uremic arterio- ferred to herein as “traditional” patients).5-9 lopathy, is a metastatic Calciphylaxis occurring in patients with calcification-induced mi- both normal renal and parathyroid func- crovascular occlusion syn- tion (referred to as “nontraditional” pa- Cdrome of mural calcification, intimal pro- tients) is considered extremely rare. Al- liferation, fibrosis, and thrombosis leading though several single case reports of to target organ hypoperfusion.1,2 Cutane- calciphylaxis occurring in nontraditional ous calciphylaxis manifests with noninflam- patients have recently been reported, the matory retiform purpura, the hallmark of literature does not reflect the increasing cutaneous microvascular occlusion syn- prevalence with which calciphylaxis is ob- dromes, for which the differential diagno- served in patients having both normal re- sis is broad, including disorders of platelet nal and parathyroid function. In addi- plugging, cold-related agglutination, ves- tion, to our knowledge, no report has sel invasive organisms, embolization, local collectively reviewed these published non- or systemic coagulopathies, and miscella- traditional cases in an attempt to identify neous conditions (calciphylaxis, Degos dis- risk factors for the development of calci- ease, and sickle cell anemia).3 Lesions of cal- phylaxis in this patient population. ciphylaxis are typically very painful, with We studied a patient with normal renal ulceration, secondary infection, and end- and parathyroid function who developed organ hypoperfusion often resulting in gan- extensive calciphylaxis. We evaluated simi- Author Affiliations: Division of grene, amputation, and sepsis with associ- lar reported cases, identifying common Dermatology (Drs Kalajian and ated mortality rates as high as 89%.4,5 characteristics among these patients that Callen), Department of Excellent comprehensive reviews of calci- may represent risk factors for the develop- Medicine (Dr Malhotra), and phylaxis have been published.5-9 ment of calciphylaxis. We hope to raise Division of Gynecologic 10-12 Oncology, Department of Since Selye and coworkers origi- awareness that the development of calci- Obstetrics and Gynecology nally coined the term in 1962, calciphy- phylaxis in nontraditional patients having (Dr Parker), University of laxis has usually been reported in pa- both normal renal and parathyroid func- Louisville, Louisville, Kentucky. tients with end-stage renal disease and tion is not as rare as previously believed. (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 4), APR 2009 WWW.ARCHDERMATOL.COM 451 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Table 1. Results of Laboratory Investigations Initial Range During Reference Laboratory Investigation Value Hospitalization Range Hemoglobin, g/dL 8.9 (↓) 7.3-11.7 11.2-15.7 White blood cells, ϫ103/µL 10.0 5.4-14.0 4.1-10.8 Platelets, ϫ103/µL 438 (↑) 344-639 140-370 Creatinine, mg/dL 0.6 (↓) 0.4-0.8 0.7-1.2 Serum urea nitrogen, 13 5-20 7-20 mg/dL Aspartate aminotransferase, 31 20-54 10-47 U/L Alanine aminotransferase, 25 11-31 10-50 U/L Alkaline phosphatase, U/L 113 88-180 38-126 Albumin, g/dL 2.9 (↓) 2.4-3.1 3.9-5.0 Calcium, mg/dLa 9.1 8.3-10.2 8.8-10.5 Ionized calcium, mg/dL 4.68 4.68-5.08 4.52-5.28 Phosphorus, mg/dL 4.6 (↑) 4.0-6.2 2.5-4.5 Calcium-phosphorus 41.8 33.1-63.4 Ͻ55 product,mg2/dL2a Figure 1. Large retiform ulceration with thick eschar on the proximal part of 25-Hydroxyvitamin D, 7b (↓) NA 20-200 the right thigh surrounded by violaceous, indurated, tender, retiform ng/mL plaques. Parathyroid hormone, 63 33-67 10-65 pg/mL 24-h urine calcium, mg 35.7b (↓) NA 45-353 b REPORT OF A CASE 24-h urine phosphorus, mg 0.37 (↓) NA 0.4-1.3 Protein C, % 106b NA 90-131 Protein S, % 119b (↑) NA 57-88 A 58-year-old woman had a 4-week history of exquis- PT, s 32.5 (↑) 12.8-54.4 9.4-11.6 INR 3.8 (↑) 1.3-6.4 0.9-1.2 itely painful ulcerations and violaceous tender plaques aPTT, s 40.8 (↑) 34.5-64.1 22-30.4 on both thighs and her lower abdomen. Seven months Homocysteine, mg/L 1.41b NA 0.60-1.68 earlier she had been diagnosed as having stage IIIc en- Factor V Leiden mutation Negativeb NA Negative dometrial carcinoma, which was treated with surgery Lupus anticoagulant screen Negativeb NA Negative Anticardiolipin IgG, IgM, All normalb NA IgG and IgM, Ͻ20; (complicated by a chronic pelvic abscess requiring per- IgA antibodies, U/mL IgA, Ͻ12 cutaneous drainage) and chemotherapy. The chemo- ␤2-Glycoprotein-1 IgG, IgG and IgM, NA IgG, Ͻ20; IgM and therapy had been completed (cycle 1 with carboplatin IgM, IgA antibodies, normalb; IgA, Ͻ10 b ↑ alone and cycles 2 through 5 with carboplatin and pac- U/mL IgA, 13 ( ) litaxel) 2 weeks before the development of the cutane- Abbreviations: aPTT, activated partial thromboplastin time; INR, international ous lesions. The patient’s medical history included obe- normalized ratio; NA, not applicable; PT, prothrombin time; ↑, laboratory value sity, hypertension, hypothyroidism, anemia, and venous is above the reference range; ↓, laboratory value is below the reference range. stasis. Active comorbidities included deep venous throm- SI conversion factors: To convert alanine and aspartate aminotransferases and alkaline phosphatase to microkatals per liter, multiply by 0.0167; albumin to bosis and Pseudomonas aeruginosa infection of both her grams per liter, multiply by 10; calcium and ionized calcium to millimoles per lower urinary tract and her right thigh ulceration. Medi- liter, multiply by 0.25; creatinine to micromoles per liter, multiply by 88.4; cations included warfarin sodium, amlodipine besylate, hemoglobin to grams per liter, multiply by 10; homocysteine to micromoles per liter, multiply by 7.397; hydroxyvitamin D to nanomoles per liter, multiply by levothyroxine sodium, epoetin alfa, paroxetine hydro- 2.496; parathyroid hormone to nanograms per liter, multiply by 1; phosphorus chloride, furosemide, oxycodone, acetaminophen, si- to millimoles per liter, multiply by 0.323; platelets to number ϫ109 per liter, methicone, senna, lorazepam, and 2% mupirocin oint- multiply by 1; serum urea nitrogen to millimoles per liter, multiply by 0.357; and ment twice daily. She denied any alterations or white blood cells to number of cells ϫ109 per liter, multiply by 0.001. aCorrected for serum albumin level. interruptions in warfarin dosing. She did not use alco- bMeasured only once during hospital course. hol, drugs, or tobacco products. Physical examination showed an afebrile, hemody- namically stable, obese (body mass index, 53 [calcu- pura on her thighs and abdomen despite culture- lated as weight in kilograms divided by height in meters directed antimicrobial therapy and replacing warfarin with squared]) woman in significant pain from a large reti- enoxaparin sodium. Initial biopsy specimens showed ne- form ulceration on the proximal part of her right thigh crosis of the epidermis and superficial dermis with fi- covered with a thick eschar surrounded by violaceous, brin microthrombi in the dermal and superficial subcu- indurated, tender, retiform plaques (Figure 1). The lat- taneous vasculature with minimal inflammation and no eral part of the thighs, the hips, and the pannus mani- vasculitis. Plain radiographs of her thighs did not iden- fested violaceous indurated plaques. She had no other per- tify tissue or vascular calcification. Persistent clinical sus- tinent cutaneous or mucosal findings. Laboratory picion of calciphylaxis prompted an incisional wedge bi- investigations are summarized in Table 1. opsy down to fascia, which showed intramural calcium Initial clinical differential diagnosis favored a vascu- deposition in subcutaneous arterioles with
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