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Kidney Week

Abstract: PO0797

Calciphylaxis and COVID-19-Associated Thrombotic Retiform Purpura in a Peritoneal Dialysis Patient

Session Information

Category: Trainee Case Report

  • 000 Coronavirus (COVID-19)

Authors

  • Varma, Elly, Weill Cornell Medicine, New York, New York, United States
  • Magro, Cynthia M., Weill Cornell Medicine, New York, New York, United States
  • Nuovo, Jerry, Weill Cornell Medicine, New York, New York, United States
  • Liu, Frank, Rogosin Institute, New York, New York, United States
  • Srivatana, Vesh, Rogosin Institute, New York, New York, United States
Introduction

The Coronavirus disease (COVID-19) pandemic has posed diagnostic and management challenges for nephrologists. We report an atypical manifestation of COVID-19 presenting as a case of Calciphylaxis and COVID-19 Associated Thrombotic Retiform Purpura in a peritoneal dialysis patient.

Case Description

A 62-year-old female presented to the emergency room with leg pain and edema for 4 weeks. She had recently been started on peritoneal dialysis. Examination revealed tender, indurated retiform dusky plaques on thighs and bilateral lower legs (Figure 1). Laboratory findings are summarised in Table1. Her SARS-COV-2-RT-PCR was positive. Imaging revealed no evidence of thrombosis. Skin biopsy showed severe ischemic dermopathy syndrome consistent with an overlap of COVID-associated thrombotic retiform purpura and calciphylaxis (Figure 2).The SARS-CoV-2 envelope protein was seen in endothelial cells within dermal blood vessels.The patient was transitioned to intermittent hemodialysis and started on intravenous sodium thiosulfate 25 grams three times weekly.

Discussion

In COVID-19 era, coagulation abnormalities are becoming increasingly evident. Management of calciphylaxis in PD patients is difficult under current circumstances due to limitations in the ability to provide regular infusions and multi-interventional care. We hypothesize that our patient had an underlying predisposition for calciphylaxis given risk factors of secondary hyperparathyroidism and an additional insult (COVID-19) caused a so-called “second hit” resulting in clinically apparent disease. Atypical presentations of COVID-19 due to a combination of procoagulant state, as well as any preexisting risk factors for calciphylaxis, must be kept in mind.

Table 1. Laboratory investigations

Sodium
Potassium
Chloride
Blood urea nitrogen (BUN)
Creatinine
Calcium, corrected
Phosphorus
Hemoglobin
Hematocrit
Platelets
Alkaline phosphatase
Parathyroid hormone (PTH)
Vitamin D 25 hydroxy (OH)
Vitamin D 1,25 dihydroxy
C-reactive protein
Erythrocyte sedimentation rate
Creatine kinase
D dimer
Lactate dehydrogenase
Complements, C3 and C4
HIV, Hepatitis B and C serologies

122mmol/L
2.9mmol/L
79mmol/L
38 mg/dL
8.32mg/dL
10.7mg/dL
4.2mg/dL
10.7mg/dL
32.3%
217 x 103/uL
140U/L
1554pg/mL
68.5ng/mL
79.7pg/mL
19mg/dL
122
516 U/L
953ng/mL
529U/L
133mg/dL and 40.3mg/dL
Negative