WSI23-111: Calciphylaxis Research Set
From MGH Learn Pathology
Request details
- Request type Faculty
- Subspecialty Dermatopathology
- Topic Calciphylaxis Research Set
- Presenter Nazarian, Rosalynn M.,MD
| Case | Clinical history | Requester |
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| Case | Clinical history | Requester |
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| Case #1 - The patient is a 66-year-old female with a history of Type 1 diabetes mellitus complicated by nephropathy • retinopathy • neuropathy • and gastroparesis. She has developed end-stage renal disease and is on Monday-Wednesday-Friday hemodialysis. Her past medical history is also notable for is atrial fibrillation for which she takes coumadin as well as chronic hypotension for which she is taking midodrine. Relevant laboratory results: Creatinine 3.88 mg/dL (Reference interval 0.6-1.50 mg/dL) • calcium 9.1 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 5.1 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 339 pg/dL (reference interval 10-60 pg/mL). On exam there is a right lower extremity wound with red granulation tissue (see clinical photograph #1). A punch biopsy is performed. | Em99 |
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| Case #2 - The patient is a 76-year-old nondiabetic female who presents for evaluation of a new right calf which was noted to have developed approximately one month prior. She described waking one morning to see a large • raised and tender blister. She is not taking coumadin. Relevant laboratory results: Creatinine 0.88 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.2 mg/dL (reference interval 8.5-10.5 mg/dL). Phosphate and PTH were not determined. On exam • she has an approximately 1 cm x 1.5 cm pink slightly scaly patch on the anteromedial right shin (see clinical photograph #2). A punch biopsy is performed. | Em99 |
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| Case #3 - The patient is a 68-year-old female with past medical history significant for chronic myelogenous leukemia currently on imatinib. She additionally has a left lung nodule • left adrenal nodule undergoing surveillance and a newly discovered liver mass • all without a pathology diagnosis. She has a history of gastrointestinal bleeds due to arteriovenous malformation. She has paroxysmal atrial fibrillation and is reportedly receiving apixaban. She has chronic obstructive pulmonary disease requiring supplemental oxygen and heart failure with preserved ejection fraction of 64%. Relevant laboratory results: Creatinine 5.92 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 8.6 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 4.9 mg/dL (reference interval 2.6-4.5 mg/dL). PTH was not determined. She presents with large edematous bullae over the left and right lower lateral shins • along with bilateral large surrounding purpuric plaques with areas of duskiness (see clinical photograph #3). A punch biopsy is performed. | Em99 |
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| Case #4 - The patient is a 67-year-old male with past medical history significant for type II diabetes mellitus complicated by end-stage renal disease on maintenance peritoneal dialysis • presenting for initial evaluation of painful right leg lesions. Relevant laboratory results: Creatinine 10.74 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.4 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 5.4 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 230 pg/mL (reference interval 10-60 pg/mL). He has been treated in past for stasis dermatitis and cellulitis without resolution of his symptoms. On exam • there is a tender right shin lesion with brawny induration and no evident purpura; the lower medial calf shows dusky discoloration (see clinical photograph #4). A punch biopsy is performed. | Em99 |
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| Case #5 - The patient is a 77-year-old female with a history of cervical and anal cancers treated with surgery • chemotherapy • and radiation. She is presenting with chief complaint of redness and lymphedema of the left thigh. Relevant laboratory results: Creatinine 0.72 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.1 mg/dL (reference interval 8.5-10.5 mg/dL. Phosphate and PTH were not determined. On exam • there is a non-blanching rash on the left thigh with stellate borders consistent with retiform purpura. Per dermatologist's note • there is no evidence of cellulitis on exam. The appearance of the rash raises concern of vasculopathy (see clinical photograph #5). A punch biopsy is performed. | Em99 |
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| Case #6 - The patient is a 65-year-old male with complex past medical history significant for type II diabetes mellitus complicated by end-stage renal disease requiring hemodialysis. He presents with painful progressive right lower extremity wounds. He has been treated with multiple antibiotics without resolution or improvement of his wounds. Relevant laboratory results: Creatinine 10.4 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 10.5 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 5.0 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 152 pg/mL (reference interval 10-60 pg/mL). On exam • there are multiple well-demarcated ulcers with necrotic tissue obscuring the wound bed (see clinical photograph #6). A punch biopsy is performed. | Em99 |
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| Case #7 - The patient is a 70-year-old female with no significant past medical history including no history of renal disease or peripheral vascular disease. She is not taking any medications. Relevant laboratory results: No laboratory studies performed. On exam • there are multiple 1-2 mm white-yellow papules on posterior neck and bilateral axillae identified (see clinical photograph #7). The patient states these lesions have been present for years. A punch biopsy is obtained. | Em99 |
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| Case #8 - The patient is a 76-year-old female with a history of a Stage IB (T1bN0) melanoma of the left lower leg diagnosed in 5 years ago and treated by wide excision. At the time • sentinel lymph node biopsy was negative for malignancy. In the interim • she has had in-transit metastases identified in the left leg which have been excised. She has no history of renal disease or peripheral vascular disease. Relevant laboratory results: Creatinine 0.66 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.3 mg/dL (reference interval 8.5-10.5 mg/dL. Phosphate and PTH were not determined. She is now presenting with a painless nodule lateral to the well-healed pre-tibial incision (see clinical photograph #8). An excisional biopsy is performed. | Em99 |
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| Case #9 - The patient is a 46-year-old female with a past medical history significant for type II diabetes mellitus complicated by end-stage renal disease requiring peritoneal dialysis • peripheral vascular disease • and atrial fibrillation maintained on coumadin. She has had multiple recent falls. She presents with chief complaint of painful indurated plaques on bilateral thighs. Relevant laboratory results: Creatinine 12.32 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 8.5 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 5.2 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 538 pg/mL (reference interval 10-60 pg/mL). The lesion is pictured in clinical photograph #9. A punch biopsy is performed. | Em99 |
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| Case #10 - The patient is a 44-year-old male with multiple sclerosis on fingolimod and steroids and worsening depression who is admitted for evaluation of AMS in setting of prolonged seizure. His hospital course complicated by acute hypoxemic respiratory failure • pulmonary emboli • and sepsis. Relevant laboratory results: Creatinine 1.16 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 8.2 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 3.3 mg/dL (reference interval 2.6-4.5 mg/dL). PTH was not determined. Dermatology is consulted to evaluate a blistering rash on the back (see clinical photograph #10). A punch biopsy is performed. | Em99 |
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| Case #11 - The patient is a 50-year-old female with past medical history significant for Evan's syndrome with subsequent autoimmune anemia and immune thrombocytopenia. She has had longstanding lymphedema as well as deep venous thromboses for which she is on coumadin. She has no history of renal disease. Relevant laboratory results: Creatinine 0.52 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 8.3 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 3.0 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 47 pg/mL (reference interval 10-60 pg/mL). The lesions initially presented as firm • red indurated lesions which were painful and have progressed to ulcers. She has had prior debridement of the lesions at an outside hospital. Dermatology was consulted to evaluate the lesions (see clinical photograph #11). A punch biopsy is performed. | Em99 |
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| Case #12 - The patient is a 35-year-old female with past medical history significant for active intravenous drug use • hepatitis C infection (previously treated and now re-infected). She has no history of renal disease or peripheral vascular disease. She presents for evaluation of chronic and new lower extremity wounds. Relevant laboratory results: Creatinine 0.78 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 10.0 mg/dL (reference interval 8.5-10.5 mg/dL). Phosphate and PTH were not determined. On exam there is palpable purpura and ulceration (see clinical photograph #12). A punch biopsy is performed. | Em99 |
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| Case #13 - The patient is a 58-year-old male with past medical history significant for chronic pancreatitis status post Whipple surgery • type I diabetes mellitus • end-stage renal disease on hemodialysis • coronary artery disease status post percutaneous coronary intervention • and significant vasculopathy status post left below-the-knee amputation • right above-the-knee amputation • and multiple finger amputations in the setting of chronic poor wound healing. He is not receiving coumadin. Relevant laboratory results: Creatinine 3.68 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 6.2 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 7.1 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 216 pg/mL (reference interval 10-60 pg/mL). On exam • he has multiple purpuric and necrotic lesions/wounds on the left lower extremity (see clinical photograph #13). A punch biopsy is performed. | Em99 |
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| Case #14 - The patient is a 50-year-old female with past medical history significant for deep venous thromboses for which she is on coumadin. She has no history of renal disease. Relevant laboratory results: Creatinine 0.98 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 8.4 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 3.6 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 47 pg/mL (reference interval 10-60 pg/mL). The lesions initially presented as firm • red indurated lesions which were painful and have progressed to ulcers. Dermatology was consulted to evaluate the lesions (see clinical photograph #14). A punch biopsy is performed. | Em99 |
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| Case #15 - The patient is a 69-year-old female with past medical history significant for metastatic pancreatic adenocarcinoma and type II diabetes mellitus. She has no history of renal disease or peripheral vascular disease. She is not receiving coumadin. She presents with chief complaint of new thigh lesions present for the last 6 weeks. Relevant laboratory results: Creatinine 0.60 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.0 mg/dL (reference interval 8.5-10.5 mg/dL). Phosphate and PTH were not determined. On exam • she has tender purpuric subcutaneous nodules on bilateral medial thighs (see clinical photograph #15). A punch biopsy is performed. | Em99 |
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| Case #16 - The patient is a 55-year-old male with past medical history significant for antiphospholipid antibody syndrome (APLS) with multiple pulmonary emboli and deep vein thromboses now on coumadin • type I diabetes mellitus complicated by end-stage renal disease requiring Monday-Wednesday-Friday hemodialysis. He has had a chronic lower extremity ulcer for the past 4 years in the setting of pressure related trauma secondary to wheelchair dependence. Relevant laboratory results: Creatinine 6.72 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.3 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 2.9 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 81 pg/mL (reference interval 10-60 pg/mL). On exam • he has a chronic non-healing lesion with no evidence of retiform purpura • no induration and without exquisite tenderness (see clinical photograph #16). A punch biopsy is obtained from the edge of the lesion. | Em99 |
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| Case #17 - The patient is a 77-year-old Caucasian female with past medical history significant for cutaneous discoid lupus erythematosus and ventricular tachycardia. She has no history of renal disease or peripheral vascular disease and is not receiving coumadin. She presents for evaluation of a new nodule on lower right leg. Relevant laboratory results: Creatinine 0.84 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.4 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 2.9 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 55 pg/mL (reference interval 10-60 pg/mL). On exam • there is a painful and tender flesh-colored nodule on the right posterior lower leg (see clinical photograph #17). A punch biopsy is performed. | Em99 |
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| Case #18 - The patient is a 62-year-old female with past medical history significant for obesity • type II diabetes mellitus • severe aortic stenosis • atrial fibrillation on warfarin • peripheral vascular disease • and end-stage renal disease on hemodialysis. She has had progressive ulcerated skin lesions of the groin which now involve her lower extremity. She endorses severe pain. Relevant laboratory results: Creatinine 7.04 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.4 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 5.6 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 504 pg/mL (reference interval 10-60 pg/mL). On exam • there are multiple wounds involving lower extremity and abdomen • some with black eschar and some with foul-smelling discharge (see clinical photograph #18). An excisional biopsy is performed. | Em99 |
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| Case #19 - The patient is a 59-year-old female with history notable for atrial fibrillation on warfarin • type II diabetes mellitus complicated by end-stage renal disease requiring hemodialysis • and peripheral vascular disease with right above-the-knee amputation. She presents with gangrene of distal left lower extremity. Relevant laboratory results: Creatinine 2.96 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 9.4 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 3.5 mg/dL (reference interval 2.6-4.5 mg/dL) • PTH 39 pg/mL (reference interval 10-60 pg/mL). On exam • there is wet gangrene of the great toe (see clinical photograph #19). The digit is amputated • and the involved skin sampled for histologic evaluation. | Em99 |
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| Case #20 - The patient is a female above the age of 89 with a history notable for atrial fibrillation on warfarin • heart failure with preserved ejection fraction (65%) • hypertension • coronary artery disease • hypertension • hyperlipidemia • and peripheral vascular disease status post right and left below-the-knee amputations in the past 3 years. She presents with chest pain • transient aphasia • and mottling and pain of the right below-the-knee amputation site. Relevant laboratory results: Creatinine 0.54 mg/dL (reference interval 0.6-1.50 mg/dL) • calcium 8.6 mg/dL (reference interval 8.5-10.5 mg/dL) • phosphate 1.8 mg/dL (reference interval 2.6-4.5 mg/dL). PTH was not determined. On exam • the right extremity was cool to the touch with mottling and dusky discoloration and with an ulcer on the right below-the-knee amputation site (see clinical photograph #20). A revision surgery is performed and the involved skin sampled for histologic evaluation. | Em99 |
