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Cutaneous gangrene in a renal dialysis patient
  1. L Pantanowitz,
  2. A Harton,
  3. B Beckwith
  1. Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
  1. Dr Pantanowitz

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Answers on p 741.

A 54 year old obese man with end stage renal disease secondary to membranous and cresentric glomerulonephritis, receiving haemodialysis, was admitted for painful necrotising abdominal and left groin wounds. He had hyperlipidaemia, coronary artery disease, peripheral vascular disease, and a 35 pack year smoking history. He was on warfarin sodium for a deep venous thrombosis. His vital signs were normal and a physical examination was remarkable for pitting pedal oedema, carotid bruits, weak left pedal pulses and large, tender, erythematous, and ulcerating subcutaneous masses of the lower abdominal wall. Blood tests revealed a glucose concentration of 6.5 mmol/l, total serum calcium 2.4 mmol/l, albumin 36 g/l, and phosphate 1.9 mmol/l. Parathyroid hormone (PTH) levels were normal and antineutrophil cytoplasmic antibody and antinuclear antibody were negative. Radiographs of his lower legs showed bilateral subcutaneous calcifications. Methicillin resistantStaphylococcus aureus,Escherichia coli, and streptococci were isolated from his wounds. A biopsy specimen (fig 1) was taken from these lesions to help make the diagnosis.

Figure 1

Photomicrograph showing circumferential and artefactually fragmented medial calcification of an arteriole with accompanying fibrointimal proliferation, both causing occlusion of the vessel lumen, with ensuing necrosis of adjacent subcutaneous fatty tissue (original magnification × 400).

Questions

(1)
What is the diagnosis?
(2)
What are the risk factors for this condition?
(3)
Can this condition occur in patients without renal disease?

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