she started hemodialysis in 2005 for chronic renal failure , and she experienced symptoms associated with hyperparathyroidism complications in 2013 . her other medical history included diabetes since 2000 , diabetic gangrene in the second toe of the right foot in 2012 , and cardiac infarction in 2013 . she visited our department for an initial examination in june 2015 , with the chief complaint of intense pain and purpura in both lower thighs . subsequently , the purpura spots rapidly formed ulcers , and she was hospitalized urgently . clearly demarcated ulcers with yellow gangrenous tissue were observed on her right ankle and several areas of her left leg . blood tests at the time of hospitalization showed elevated levels of intact parathyroid hormone ( 1,250 pg / ml ) , calcium ( 10.4 mg / dl ) , and phosphate ( 6.4 mg / dl ) , along with hyperparathyroidism . her white blood cell count was 13,200/l and c - reactive protein level was 12.77 mg / dl , indicating inflammation . computed tomography of the legs showed extensive calcification from the external iliac artery to the artery of the extremities ( fig . 1 ) . however , her ankle - brachial index indicated that blood flow was maintained relatively well ( right , 1.13 ; left , 0.94 ) . skin biopsy of the periphery of the ulcers showed calcification of the intima media of the small arteries in the dermis , and extensive inflammatory cell infiltration was observed in the periphery . wound therapy was performed for the ulcers , and following therapy , healthy granulation tissue formed . one month after hospitalization , she complained of acute pain in the left hip during rest . a radiograph revealed fracture of the left femoral neck and thinning of the cortical bone . based on the findings emergency surgery was not performed , considering her general condition , the presence of intractable ulcers in the surgical field , and the possibility of the development of new ulcers because of skin resection . we selected preservation therapy . in the second month after onset , new ulcers formed in the right groin and vagina ( fig . the ulcer in the groin was infected owing to stool contamination , and a subcutaneous gas pattern was observed in the abdomen . on the same day , in 1961 , selye et al .   reported the first case of calciphylaxis ( phenomenon of acute ectopic calcification on the skin and the whole body ) . calciphylaxis occurs mainly in end - stage renal failure patients undergoing hemodialysis , and the main symptoms are intense pain and refractory skin ulcers . this disease is refractory and has a very poor prognosis [ 3 , 4 , 5 ] . it occurs in 14% of end - stage renal failure patients , frequently manifesting on the torso and limbs . it is characterized by calcification of the tunica media of the small and medial arteries in the dermis and subcutaneous fat tissues , and necrosis of tissues due to blockage of the lumen . the present patient was diagnosed with calciphylaxis based on biopsy assessment conducted at the time of hospitalization . metabolism disorders of calcium and phosphate , decline in vitamin d3 production , hyperparathyroidism , intake of warfarin or prednisolone , low albumin , and external injuries are known causal factors of calciphylaxis . in the present patient , hyperparathyroidism from long - term dialysis and resulting abnormal metabolism of calcium and phosphate are believed to have provoked this condition . our search of the literature revealed no previous case involving complications of a vaginal ulcer and rectovaginal fistula . generally , possible treatments for a rectovaginal fistula include rectovaginal closure surgery , colostomy , and conservative therapy . although we considered surgery for the rectovaginal fistula , we opted not to perform surgery because of the possibility of the development of new ulcers at the laparotomy site and intestinal resection site . performed a colectomy in a patient with calciphylaxis , but could not close the laparotomy site after surgery . necrosis of the penis owing to calciphylaxis has been reported to respond more favorably to conservative treatment than to surgery [ 9 , 10 ] . a surgical approach for calciphylaxis can stimulate the sympathetic nerves and may cause the formation of new ulcers . therefore , surgery may worsen the calciphylaxis prognosis , suggesting that surgical treatment should be selected with caution after careful consideration of the risks to the patient 's condition and general risks . currently , treatment for calciphylaxis involves whole - body management , including prevention of infection , correction of the abnormal metabolism of calcium and phosphate , and local management of ulcers by debridement . in recent years , treatment with sodium thiosulfate has been gaining attention [ 11 , 12 , 13 ] . in the present case , cinacalcet acts directly on the calcium receptors in the parathyroid cells and inhibits parathyroid hormone without elevating blood serum calcium levels . previous reports have mentioned improvement in calciphylaxis with the administration of cinacalcet . however , in the present case , new ulcers formed after the correction of blood serum calcium and phosphate levels with cinacalcet . this rapid progression may have been prevented if the administration had been started in the early stages of the disease . this patient was diagnosed with calciphylaxis based on ulcers on both thighs , which was followed by complications of femoral neck fracture , groin ulcers , and a rectovaginal fistula . dermatologists are often involved in the treatment of this disease , and they should be well acquainted with the pathology of calciphylaxis and its symptoms in order to offer appropriate treatment from an early stage .
calciphylaxis causes ischemia in multiple organs and skin ulcers owing to progressive calcification in small and medial arteries . 
 it has a poor prognosis and often occurs in patients with hyperparathyroidism associated with end - stage renal failure and those undergoing hemodialysis . here , 
 we present a case of calciphylaxis associated with a wide range of symptoms , including lower thigh skin ulcers , a rectovaginal fistula , and femoral neck fracture . 
 the patient underwent multiple treatments . 
 however , she eventually died of cardiac failure .