Penile lesion in a dialysis patient: Time to get an X-ray.

Calciphylaxis or calcific uremic arteriolopathy is a rare and serious disorder typically seen in patients with end-stage renal disease that manifests as skin ischemia and necrosis and histologically characterized by calcification of dermal arterioles. Penis is a rare site of involvement and biopsy is not typically recommended, making the diagnosis clinico-radiologic.

CASE

A 34‐year‐old man with end‐stage renal disease secondary to diabetes mellitus, on hemodialysis for 2 years, was seen for worsening pain and blackening of the skin in the penile region that started a month ago. He denied fever, painful urination, discharge from the urethra, or unprotected sexual intercourse in the recent past. Examination revealed mild edema and superficial necrosis of the foreskin and glans penis (Figure 1A). Laboratory data demonstrated a high blood urea nitrogen of 100 mg/dL, serum creatinine 12.2 mg/dL, parathyroid hormone 400 pg/mL, and calcium–phosphorus product 111 mg/dL. Plain radiographs of the pelvis demonstrated widespread vascular calcification (Figure 1B). We diagnosed the patient with penile calciphylaxis and initiated intravenous sodium thiosulfate therapy, intensification of dialysis regimen, and phosphate control.

Figure 1

A, Edematous foreskin and superficial necrosis of the penis. B, Plain radiograph demonstrating extensive calcifications of the pelvic and lower extremity vessels

While most lesions of calcific uremic arteriolopathy (CUA) occur on the lower extremities and lower abdomen, rare sites such as breast and penis have been reported.1, 2 High calcium–phosphate product, secondary hyperparathyroidism, hypoalbuminemia, diabetes, obesity, warfarin use, female sex, and protein C/S deficiency are among the risk factors, and skin biopsy is the gold standard of diagnosis. However, biopsy is not typically recommended for penile lesions because of the risk for progression of necrosis, and therefore, penile CUA essentially remains a clinico‐radiologic diagnosis.2 The overall prognosis of this condition is poor with mortality rates exceeding 60%. In cases of severe secondary hyperparathyroidism, parathyroidectomy may offer survival benefit compared to local debridement or penectomy alone.3

CONFLICT OF INTEREST

The authors have declared that no conflict of interest exists.

INFORMED CONSENT

Obtained from the patient.

AUTHORSHIP

Both the authors made substantial contribution to the preparation of this manuscript. AK was the Attending Nephrologist on the case.