33396 Nonuremic calciphylaxis precipitated by COVID 19 infection

Abstract

A 40-year-old female with a medical history of hypertension, anxiety, and COVID-19 pneumonia in May 2021 that was complicated by cardiac arrest, presented in July 2021 with bilateral lower extremity wounds. Wounds initially were described as ‘sunburns’ that progressed to form multiple large retiform purpura with black necrotic eschars and surrounding induration on bilateral thighs and lower legs. A telescoping punch biopsy was performed showing calciphylaxis with intravascular thrombosis. Labs were significant for a mildly elevated phosphorus, PT/PTT, lupus anticoagulant antibody, and positive ANA. Creatinine, BUN, calcium, PTH, and GFR were within normal limits. Patient had no prior personal or family history of coagulopathies or renal dysfunction. The patient was diagnosed with nonuremic calciphylaxis (NUC) precipitated by a COVID-19 induced coagulopathy. Intravenous sodium thiosulfate and sevelamer was started for treatment. NUC is a rare disease characterized by arterial calcification leading to ischemia and skin necrosis that occurs in the setting of normal renal function. Other conditions associated with NUC include prothrombotic states like Protein C and S deficiency, antithrombin III deficiency, antiphospholipid antibody, cryofibrogenemia, and malignancy. COVID-19 has been demonstrated to generate a prothrombotic state leading to hypercoagulability. The patient’s recent COVID-19 infection and positive lupus anticoagulant antibody together promoted a hypercoagulable state that was the nidus for cutaneous calciphylaxis and making this case of NUC induced by COVID-19 hypercoagulability a novel presentation of an uncommon disease.