This case presentation describes a 70-year-old female patient on long-term hemodialysis who developed painful skin lesions on her legs and feet. She was diagnosed with calciphylaxis, a condition caused by abnormal calcium and phosphate metabolism. After starting warfarin treatment for atrial fibrillation, she developed necrotic skin lesions characteristic of calciphylaxis. Her condition deteriorated and she suffered another stroke and died within a week, highlighting the life-threatening nature and high mortality of calciphylaxis.

1. CASE PRESENTATION
BY:
Dr: Amany Abdelgawad Farag
Egyptian Nephrology Fellowship trainee At NMGH

2. PERSONAL HISTORY
• 70 year old female patient from Sandoub, married, housewife with no special
habits of medical importance.

3. PAST HISTORY
• Not diabetic nor hypertensive.
• ESRD on regular hemodialysis for 6 years.
• History of cerebral stroke 2 years ago.

4. COMPLAINT
• Skin lesions on both legs and feet.

5. PRESENT HISTORY
• The condition started 1 month ago by being diagnosed as chronic AF with both
mitral and tricuspid regurge.

10. • Warfarin usage was followed by appearance of necrotic painful skin lesions on
both feet and legs of variable size and shape.

14. DIAGNOSIS
CALCIFIC URAEMIC ARTERIOLOPATHY
(CALCIPHYLAXIS)

15. SERUM Ca: 9
Serum PO4: 5
PTH: 200
The patient was on no vitamin D analogues.
Skin biopsy was asked to confirm diagnosis but the husband refused.
The patient was asked to consult her cardiologist to change warfarin to new oral
anticoagulants.
The cardiologist insisted on using warfarin even the least dose 1mg.

18. • Few days later, the patient had a new cerebral stroke and was prescriped
piracetam injections after each session and piracetam capsules bd by
neurologist.
• The patient died 1 week later.

19. Calciphylaxis is a small vessel
vasculopathy resulting in ischaemia and
necrosis of skin, soft tissue, visceral
organs and skeletal muscle.
Mortality is about 45 % at 1 year .

20. MANAGEMENT OF CALCIPHYLAXIS
Appropriate analgesic.
Wound care and avoidance of trauma (e.g. SC injections).
Lower calcium phosphorus product, avoid calcium based binders,discontinue
vitamin D analogues, daily dialysis.
Aggressive control of PO4
Parathyroidectomy if needed
Stop warfarin.
Hyperbaric oxygen.

21. IV Sodium thiosulphate to relieve pain and enhance wound granulation.

22. THANK YOU