An 81-year-old woman with past medical history of diabetes, hyperlipidemia, atrial fibrillation, and hypertension was seen in the dermatology clinic for ulcers on her left thigh for 2 months. The lesions were initially black painful skin discolorations. She was empirically treated with prednisone without improvement. Over time, the overlaying skin erupted revealing deep ulcers underneath. Her medication included metoprolol, amlodipine, insulin, and warfarin for atrial fibrillation.
Physical examination revealed several deep ulcers 2-3 cm in diameter, with eschars and surrounding erythema (Figure 1). Punch biopsy of the left calf skin showed dystrophic calcifications involving subcutaneous vessels, findings consistent with calciphylaxis.
Laboratory studies showed:
- Serum creatinine 0.52 mg/dL
- Blood urea nitrogen (BUN) 11 mg/dL
- Serum calcium 11.2 mg/dL, phosphorus 4.7 mg/dL (normal 2.7-4.5 mg/dL)
- TSH 1.52 mIU/L
- Liver function tests are normal.
- 25-OH vitamin D level is 27 ng/mL
- Serum protein electrophoresis showed no paraproteins.
- Hemoglobin A1c is 6.2
- All serologies were negative, including ANA, ANCA, dsDNA, lupus anticoagulant, anti-cardiolipin, anti-SSA/SSB, anti-RNP, anti-Smith, rheumatoid factor, cryoglobulin.