Clinical Images

Recurrent dry gangrene and ulceration of the fingers and glans penis

   A 58-year-old male with end-stage renal disease (ESRD), type 2 diabetes mellitus, long-term warfarin use for arteriovenous graft patency, and digital gangrene status post multiple finger amputations presented with painful ulcerations of his left 4^th finger and penis.

   Physical examination was significant for ulceration and dry gangrene of the 4th finger (Figure 1a) and an exquisitely tender 2x2 cm dry shallow ulcer on the glans penis. X-ray of the left hand revealed extensive arterial calcification (Figure 1b). Pathology from a subsequent transmetacarpal amputation was significant for gangrenous necrosis of the skin and soft tissue and severe calcific atherosclerosis. Given the physical exam, X-ray, and pathology findings, the patient was diagnosed with calciphylaxis.

MCQ 1: Which of the following is the most significant risk factor for developing calciphylaxis? 

1. Systemic steroids
2. End-stage renal disease
3. Obesity
4. Female sex
5. Diabetes mellitus

MCQ 2: Which of the following medications has the greatest risk for calciphylaxis in patients with ESRD

1. Warfarin
2. NSAIDs
3. Digoxin
4. Amiodarone
5. Bisphosphonates

Click here for answers.

References:

1.         Nigwekar SU, Kroshinsky D, Nazarian RM, Goverman J, Malhotra R, Jackson VA, et al. Calciphylaxis: risk factors, diagnosis, and treatment. Am J Kidney Dis Off J Natl Kidney Found. 2015 Jul;66(1):133–46.

2.         Kazanji N, Falatko J, Neupane S, Reddy G. Calciphylaxis presenting as digital ischemia. Intern Emerg Med. 2015 Jun;10(4):529–30.

3.         Barbera V, Di Lullo L, Gorini A, Otranto G, Floccari F, Malaguti M, et al. Penile calciphylaxis in end stage renal disease. Case Rep Urol. 2013;2013:968916.

4.         Mochel MC, Arakaki RY, Wang G, Kroshinsky D, Hoang MP. Cutaneous calciphylaxis: a retrospective histopathologic evaluation. Am J Dermatopathol. 2013 Jul;35(5):582–6.

5.         Jeong HS, Dominguez AR. Calciphylaxis: Controversies in Pathogenesis, Diagnosis and Treatment. Am J Med Sci. 2016 Feb;351(2):217–27.

Author biographies:

Jonathon Wanta is a third year medical student at Case Western Reserve University in Cleveland, OH. He received his bachelor’s degree in psychology and Spanish from Case Western Reserve University and plans to attend a residency program in psychiatry after graduation. .

Sally Namboodiri, MD is an assistant professor of medicine at Case Western Reserve School of Medicine and is an internist at the Louis Stokes Cleveland VA Medical Center.

Clifford D. Packer, MD is a professor of medicine at Case Western Reserve School of Medicine and the internal medicine clerkship director at the Louis Stokes Cleveland VA Medical Center. His academic interests include high-value care, service-learning, the use of case reports in medical education, and the medical humanities.