Prepared by Imo A. Ebong, MD, Medical Resident, Department of Internal Medicine, Huron Hospital, Cleveland, Ohio

A 55-year-old obese black woman presented with extensive, painful, necrotic skin lesions on her anterior abdominal wall, back, and upper thighs (Figure 1). Her medical history included hypertension and end-stage renal disease, for which she received daily peritoneal dialysis. She denied any antecedent trauma or use of anticoagulants. Laboratory test results were: serum calcium, 1.98 mmol/L; phosphorus, 4.1 mmol/L; serum albumin, 16 g/L; parathyroid hormone, 410.78 pmol/L; white blood cell count, 0.021 x 10⁹/L. A skeletal survey showed generalized demineralization affecting multiple bones. Skin biopsy was performed (Figure 2). Despite aggressive and appropriate therapy, the patient died from sepsis complications.

What?s the Diagnosis?

Warfarin-induced skin necrosis
Pyoderma gangrenosum
Calcific uremic arteriolopathy
Lupus panniculitis