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 had 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 violaceous plaques with necrotic changes in both legs, with some blisters on the left leg ( Fig. 1 ). Skin biopsy showed arterial occlusion with calcium salt deposits with von Kossa reaction, necrosis of the small vessels, and epithelial necrosis ( Fig. 2 ). A crystallographic study of the skin was performed showing 100% calcium oxalate crystals (wedellita). Necrotic and ulcerated plaque with blisters on the skin on the left leg image von Kossa‐stained tissue revealed calcium deposits in blood vessels ( × 40) image Laboratory tests revealed a hematocrit of 27%, increased calcium/phosphate (Ca 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 glucose 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 showed signs of bone resorption: subperiosteal erosions in phalangeal bones, vascular calcifications. Bone biopsy showed massive oxalate crystal deposits. She underwent a parathyroidectomy. Unfortunately, she suffered a terminal cardiac arrest in the immediate postoperative period.