Session: FRI 368-390-Metabolic Bone Disease Case Reports (posters)
Poster Board FRI 372
Clinical Case: A 65-year old Caucasian man presented with new hypercalcemia and a painful 1.2-cm area of indurated, dusky plaque with central necrosis on his posterior left calf. The lesion expanded the week prior despite antibiotics. He had type 2 DM, HTN, CKD stage 3, obesity, CHF, paroxysmal afib, and OSA on CPAP. His medications included insulin, losartan, metoprolol, pravastatin, amiodarone, and warfarin. A skin punch biopsy showed perivascular calcium deposits in small vessels around adipose tissue and non-inflammatory thrombi, consistent with calciphylaxis. On admission, his corrected calcium was 13.3 mg/dl, creatinine was 2.5 mg/dL (baseline of 1.5), with normal phosphate, an appropriately low PTH of 4 pg/ml, a normal PTHrP, a normal 25-OH vitamin D, an elevated 1,25-OH vitamin D of 92 pg/ml, and HbA1c of 7.6%. CRP was elevated at 1.83 mg/dl and peaked to 2.02 mg/dl (n<1 mg/dl). Frequent wound care and STS infusion (12.5 g every other day) were started. Evaluation of hypercalcemia revealed numerous non-caseating granulomas on bone marrow biopsy, which was deemed to be mostly likely due to amiodarone. Amiodarone was discontinued, and with isotonic fluids and a single dose of pamidronate (30 mg IV), hypercalcemia resolved within a few days. The left calf lesion improved by discharge 2 weeks later, but its size increased and a new skin lesion appeared on his right calf after 5 weeks of STS and wound care, Therefore, weekly pamidronate (30 mg IV) was initiated, resulting in normalization of CRP after 3 months and gradual resolution of all skin lesions at 5.5 months after initial presentation. After the skin lesions resolved, STS was continued for 2 weeks (a total of 6 months) and pamidronate for another 4 weeks (a total of 5 months) The patient has remained normocalcemic and without skin lesions one year after conclusion of all therapy.
Conclusion: This patient’s presentation of calciphylaxis is notable for the atypical features: non-uremia and hypercalcemia (without hyperparathyroidism) likely secondary to a complication of amiodarone use. In this setting, we observed that weekly pamidronate in conjunction with STS was more effective in managing NUC than STS alone.
Nothing to Disclose: KC, CD, TS, JSL
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