The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 17

derm dilemma Special Section: Short Dermatological Cases by Amanda ederle, md candidate, class of 2020 uams dept of dermatology A 67-year-old female with medical history significant for end stage renal disease, diabetes mellitus, and morbid obesity presents to the emergency room with a five-to-six-day history of livedo reticularis and exquisitely painful, firm, stellate purpura of the thighs, lower legs, abdomen, and buttocks. The patient also has a history of secondary hyperparathyroidism and an elevated calcium-phosphate product. Physical examination revealed the findings seen in the image.. The therapeutic intervention most likely to result in long-term control and decreased morbidity/ mortality is: A. Irrigation and vigorous debridement B. Intravenous sodium thiosulfate C. Reassurance and observation D. Peritoneal hemodialysis E. Intravenous vitamin K Answer: B - IV sodium thiosulfate The patient has calciphylaxis, a relatively uncommon disorder occurring primarily in the setting of end stage renal disease, which is characterized by painful ulcerations and necrosis of the skin and subcutaneous tissue. Mortality is high, and often the result of sepsis. Though the pathogenesis of calciphylaxis is not fully understood, clinical findings suggest it results from ischemia and necrosis caused by calcification and subsequent thrombus formation within arterioles of the skin and subcutis. Risk factors for calciphylaxis include end stage renal disease, female sex, obesity, hypercalcemia, hyperphosphatemia, elevated parathormone level, and concurrent use of warfarin. Areas of the body with high fat content, such as the lower extremities, abdomen, and buttocks, are typically affected. Deep-wedge biopsy demonstrates calcification within the media of small- and medium-sized arterioles (which may be visualized with plain radiography), intimal hyperplasia and fibrosis, and intraluminal microthrombi. In addition to the painful skin lesions, some patients will have concurrently elevated calcium, phosphorus, or parathyroid hormone; thus, phosphate binders, low calcium bath dialysis, bisphosphonates, calcimimetics, and even subtotal parathyroidectomy may be employed. The six-month mortality rate of this disorder is approximately 50%, and mounting evidence suggests that IV sodium thiosulfate, a potent antioxidant, is effective in solubilizing calcium. Meticulous wound care, pain management, and treatment of secondary microbial infections are also important aspects of treatment. Sodium thiosulfate therapy is typically continued for several months, and response is monitored by a decrease in the number, size, or pain of calciphylaxis ulcerations/eschars. DocbookMD Transitions to Medici Connect DocbookMD has transitioned to Medici Connect, and AMS members have an exclusive, free membership to use this communications app. Medici Connect combines the previous features of DocbookMD with new upgrades that include telemedicine. Users will now be able to send HIPAA-compliant voice, video, and text messages to both patients and colleagues, and have access to eReferrals, group messaging, and a network of AMS doctors. The account also comes with the availability to communicate from your Android or iPhone device or the web and a signed Business Associate Agreement. If you had a Docbook account, you will be receiving an email with instructions on how to create your Medici Connect account. This email will include a personalized link that gives you a quicker registration process. If you did not receive an email, you can click here and create your account (https:// app.medici.md/#/auth/register). If you are a current member and do not have a Docbook account, contact us at [email protected] and we will add you to our network. Medici Connect is a $300 yearly value that we provide for our members as an exclusive benefit. If you are not an AMS member, but would like to join our Medici Connect network, visit https://www.arkmed. org/membership/join-renew/ to become a member. Volume 116 • Number 12 JUNE 2020 • 281