Two patients on hemodialysis for chronic kidney failure developed fever. The first patient was a 53-year-old woman who was seen for a painful and indurated necrotic plaque that had developed 20 days earlier on the anterior aspect of the right thigh (Fig. 1A). The relevant findings in the laboratory tests were calcemia, 8.6mg/dL, and parathyroid hormone, 569pg/ml. On computed tomography there were areas of calcification in the subcutaneous cellular tissue beneath the lesion, and skin biopsy was compatible with calciphylaxis. Treatment was started with sodium thiosulfate 20mg/48h and meropenem 500mg/12h but the lesions did not improve and the patient died. The second patient was a man aged 56 years who was seen for an indurated, painful plaque on the lateral aspect of the thigh. The plaque had a central blister of serous fluid with a necrotic base (Fig. 1B). Histopathology revealed necrotizing panniculitis and Pseudomonas aeruginosa was cultured from the skin biopsy. The patient was diagnosed with ecthyma gangrenosum and the lesion healed after 10 days of treatment with ciprofloxacin 250mg/12h. Calciphylaxis and ecthyma gangrenosum in patients with chronic kidney failure are rare conditions due, respectively, to secondary hypoparathyroidism and immunosuppression. Both conditions are painful and are usually associated with fever. The clinical manifestations are similar in the initial stages, and recognition is therefore important to avoid a delay in starting treatment.

Figure 1.

A, Indurated erythematous plaque with a central ulcer on the anterior aspect of the right thigh. B, Indurated erythematous plaque on the lateral aspect of the right thigh; there is a central blister of serous fluid with a necrotic base.

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