CALCIPHYLAXIS (CUTANEOUS AND SYSTEMIC CAL CIFICATIONS)

History and clinical findings: Acute, zigzag-shaped livid skin marking s developed on both thighs of a 55-year-old woman who had been on dial ysis for 6 years. Within 7 days these areas increased in size to about 10 cm in diameter and contained central dry and painful necroses. On legs, lower arms and hands hard subcutaneous nodules were palpable wit h a diameter up to 3 mm. For many years the phosphate and parathormone levels, as well as alkaline phosphatase activity had been raised. The patient had often failed to follow treatment recommendations. Tests: There were increased serum concentrations of calcium (2.8 mmol/l) and phosphate (1.78 mmol/l). The calcium phosphate ion product was 4.98 (m mol/l)(2). Furthermore, there were raised levels of alkaline phosphata se (315 U/l) and parathormone (1076 ng/l, normal: 10-65). X-ray film o f the hands showed soft tissue and arterial calcifications, while hist ological examination of a deep skin biopsy revealed calcium phosphate emboli of the main vessels. Treatment and course: Excision of the cuta neous necroses was followed by parathyroidectomy at which only three p arathyroid glands were identified and removed. The parathormone level fell postoperatively, but rose again after 4 weeks. The fourth parathy roid gland was then found and removed, after which the parathormone le vel fell below measurable levels. The skin ulcers healed completely 4 weeks after the second operation.