Medical image. A rare but fatal complication of end stage renal disease

ClinicalA 49-year-old male with end stage renal disease (ESRD) on haemodialysis was referred for further management of painful, extensive bilateral lower extremity ulcerations present for 8 months (Figure 1). Figure 1. Lower extremity ulceration and overlying eschar Significant labs were leukocytosis, elevated calcium-phosphorus product (CaxP) of 97.5 mg2/dl2 and parathyroid hormone (PTH) level of 3708 pg/ml (10-60). Biopsy of the cutaneous lesions revealed epidermal and dermal necrosis, thrombosis and calcifications in small blood vessels of subcutis (Figure 2). Figure 2. (A) Skin biopsy showing dermal necrosis with neutrophilic infiltration, subcutaneous arterial vessel with thrombosis, marked intimal proliferation and near circumferential calcification causing occlusion of the lumen. H&E magnification 00d7100; (B) Inset showing the thrombosed vessel with circumferential calcification in the vessel wall (black arrows). H&E magnification 00d7400 What is the diagnosis? Answer and Discussion