Arrival of the patient to the emergency department
You are an emergency physician. A 48-year-old woman arrives.
A month ago, a dog jumped on her, causing bruises on her thighs through a blanket. Over the past few days, the bruises have worsened, and one has spread to her calf. She has been covering the affected areas with bandages and applying an antiseptic ointment. She complains of significant, worsening pain in her thighs. Additionally, the “bruise” has started to turn slightly black over the past few days. The patient is requesting analgesics. She reports that the pain is present even at rest and wakes her up from sleep.
On examination, you observe firm subcutaneous tissue that is very tender to touch, with the development of a deep defect featuring a several-millimeter-wide black necrosis of the skin and subcutaneous tissue. What will be your approach?
This is a classic description of calciphylaxis development!
The progression is rapid—within a few days. The initial "bruise" takes on a mottled, livedo reticularis appearance. Even before deep black necrosis forms, the subcutaneous tissue is already affected. In some cases, a native X-ray may show irregular clusters of calcifications in the subcutaneous tissue, but this is not always present. The patient describes hardening in the subcutaneous tissue.
The wounds are extremely painful, and neither rest nor limb elevation provides relief – this indicates that the pain is different from that seen in peripheral arterial disease.
Calciphylaxis typically occurs in areas with more subcutaneous fat, meaning it is not usually found at the very periphery of the limbs.
