Fatal cutaneous necrosis in a hemodialyzed patient with oxalosis

A 49-year-old woman had a history of recurrent nephrolithiasis and urinary infections since childhood that resulted in end-stage renal disease. She ha d been receiving hemodialysis for 4 years. Four months before her admission to hospital, she was to have undergone a bilateral nephrectomy but, during anesthesia induction, she suffered a cardiac arrest and the operation was interrupted. Shortly thereafter she developed skin lesions. Clinical features included bilateral livedo reticularis and painful violace ous plaques with necrotic changes in both legs, with some blisters on the l eft leg (Fig. 1). Skin biopsy showed arterial occlusion with calcium salt d eposits with von Kossa reaction. necrosis of the small vessels, and epithel ial necrosis (Fig. 2). A crystallographic study of the skin was performed s howing 100% calcium oxalate crystals (wedellita). Laboratory tests revealed a hematocrit of 27%, increased calcium/phosphate (Ga 9.8 meq/L; phosphate 14.9 meq/L), blood urea 159 mg/dL, creatinine 9.1 mg/dL, albumin 1.92 mg/dL, serum uric acid 11 mg/dL, diabetes (serum glucos e 148 mg/dL), and hyperparathyroidism (serum parathormone 150 pg/ml). X-Ray of the hands showed soft tissue calcium deposits. X-Ray of the legs s howed signs of bone resorption: subperiosteal erosions in phalangeal bones, vascular calcifications. Bone biopsy showed massive oxalate crystal deposi ts. She underwent a parathyroidectomy. Unfortunately, she suffered a terminal c ardiac arrest in the immediate postoperative period.