Title : Ulcer in a dialysis patient:
calciphylaxis
or something simpler
Author : Mohamed Amr, MD.
Salem Thabet, MD.
Affiliation : Department of Internal Medicine, Rochester General
Hospital, Rochester, NY.
Corresponding Author : Mohamed Amr, MD
Contact number : 718-764-7202
Affiliation Address : 1425 Portland Avenue, Rochester, NY,
14621.
Email address : amrelwagdycardiol@gmail.com
Funding source : none
Conflict of interest : none
Article type : Clinical image
Word count : 230
Consent: patient verbal permission had been obtained to publish
his images. The approval had been documented in his electronic medical
record. In the setting of the COVID pandemic, the use of paperwork is
prohibited per Rochester regional health policy
A 56-year-old male with a past medical history of end-stage renal
disease on regular hemodialysis, streptococcal endocarditis four years
ago, COVID-19 pneumonia three months ago, Who presented to the ED with a
complaint of wounds on both legs, as shown in the image.
He reported severe itching for two months, and the ulcers started three
weeks before presentation. The ulcers were initially painful, later
painless, initially on the right foot, later on, both right and left
foot, and the lower legs on both sides. He denied IV drug abuse, and his
drug screen had been negative. His physical exam had been normal other
than the leg ulcers, with no systemic signs of infection and no fevers.
Infective endocarditis had been ruled out with negative blood cultures
and a negative transthoracic echocardiogram. Given that the clinical
picture was not clear, multiple skin biopsies were performed, and it
showed no evidence of vasculitis, or infectious process,
or calciphylaxis. The epidermis adjacent to the ulcer is
reactive/hyperplastic, and the changes were suggested to be secondary to
CKD-associated pruritis. The patient received Triamcinolone cream with
Antihistaminic and local wound care, and the ulcers improved.
The key clinical message To know the differential
diagnosis of ulcers in a dialysis patient. We thought about vasculitis,
infectious process, and calciphylaxis, but it ended up being something
much more straightforward related to CKD pruritis.