PMC7991460_01
Right calf showing tender erythematous nodule with necrosis. Reproduced with permission from: Nigwekar SU, Thadhani RI. Calciphylaxis (calcific uremic arteriolopathy). In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on June 19, 2020) Copyright  2019 UpToDate, Inc. For more information visit www.uptodate.com.
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F1
Physical examination was notable for several tender erythematous subcutaneous nodules with necrosis on her thighs and calves bilaterally (Fig. 1).
Left thigh punch biopsy of a deep dermal blood vessel showing mural calcification without intimal proliferation, microvascular thrombosis, necrosis, or extravascular calcium and phosphorus deposits (x200 magnification).
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F2
This yielded a mural calcification of a single deep dermal blood vessel without microvascular thrombosis, necrosis, or extravascular calcium and phosphate deposits (Fig. 2).
99mTc-methylene diphosphonate bone scan, anterior views. a No activity in the lungs and thighs 5 months prior to starting hemodialysis. b Extensive activity throughout the lungs and thighs, right greater than left. c Persistent activity in the lungs and thighs despite optimization of hemodialysis and control of bone mineral metabolism. d Persistent activity in the lungs but decreased activity in the thighs after 1 month of sodium thiosulfate.
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F3
Five months prior to admission, a bone scintigraphy was obtained to evaluate the cause of her rib pain (Fig. 3a); it showed no activity in the lungs or soft tissues. The bone scintigraphy at the time of CUA diagnosis, however, demonstrated extensive increased activity throughout the lungs and lower extremities (Fig. 3b). Despite adequate dialysis clearance and optimal control of bone mineral parameters, a repeat bone scintigraphy performed 1 month after the diagnosis showed no changes in metastatic CUA (Fig. 3c). Clinically, we observed slight improvement of the localized CUA on the patient's thighs, but the metastatic pulmonary CUA on the last bone scintigraphy obtained 2 months after the diagnosis remained unchanged (Fig. 3d).