Calciphylaxis of the fingers.

A 69-year-old Japanese man with a 10-year history of hemodialysis for end-stage renal disease presented with painful necrosis of the fingers of his right hand. A plain radiograph of the right hand revealed severely calcified arteries, particularly in the ring finger, suggesting the diagnosis of calciphylaxis of the fingers.

A 69‐year‐old Japanese man with a 10‐year history of hemodialysis for end‐stage renal disease secondary to chronic glomerulonephritis presented with painful necrosis of the fingers of his right hand. He received warfarin (1 mg/d for 1 year) for paroxysmal atrial fibrillation. He had a history of hypertension; however, he denied a history of diabetes, collagen disease, or other cardiovascular diseases. Physical examination revealed dry gangrene at the tips of his middle and ring fingers and the proximal interphalangeal joint of the middle finger (Figure 1A). A plain radiograph of the right hand revealed severely calcified arteries, particularly in the ring finger (Figure 1B). Laboratory investigations revealed the following results: white blood cell count 6160/μL, serum hemoglobin 10.3 g/dL, platelet count 186 000/μL, serum calcium 9.6 mg/dL, phosphorus 3.1 mg/dL, serum albumin 3.8g/dL, and serum parathyroid hormone 172 pg/mL. Differential diagnosis included diabetic macroangiopathy, arterial occlusion, or polyarteritis. He did not have a history of diabetes or other symptoms of polyarteritis. Since skin perfusion pressure test results were within the normal range, arterial occlusion was unlikely. Based on these findings, he was diagnosed with calciphylaxis of the fingers. Administration of oral warfarin was discontinued, and he received conservative treatment for the necrotic dry lesions of the fingers.

Figure 1

Clinical image showing painful necrosis with eschar at the tips of the middle and ring fingers and the proximal interphalangeal joint of the middle finger of the patient's right hand (A, arrows). Plain radiograph of the right hand showing severely calcified arteries, particularly in the ring finger, extending to the peripheral tissue (B, arrows)

Calciphylaxis is a syndrome of arterial calcification with consequent tissue necrosis, which most commonly occurs in patients with chronic kidney disease undergoing hemodialysis.1 Warfarin inhibits vitamin K‐dependent carboxylation of matrix Gla protein (an inhibitor of local calcification); thus, warfarin administration is a risk factor for calciphylaxis.2 Calciphylaxis is associated with a mortality rate as high as 80%, and death usually occurs secondary to wound infection and sepsis.3 Plain radiography is a useful diagnostic modality for the identification of vascular calcification and shows a sensitivity of 90% in detecting such lesions.4 Although uncommon, clinicians should consider calciphylaxis in the differential diagnosis in patients with a typical clinical presentation, particularly in those undergoing long‐term dialysis. Physicians should be aware that warfarin is associated with increased risk of calciphylaxis.

CONFLICT OF INTERESTS

The authors declare no conflicts of interest in association with this study.

INFORMED CONSENTS

The authors have stated explicitly that there are no conflicts of interest in connection with this article.