African American Female Patient Research Articles

Demonstrating antibiotic stewardship while diagnosing and treating bilateral pseudoseptic arthritis: a case report

IntroductionAlthough viscosupplementation is a commonly used treatment for osteoarthritis and is widely regarded as a safe treatment option, it is associated with the rare complication of pseudoseptic arthritis. Most existing case reports that cite this rare complication employed the use of early broad-spectrum antibiotics.Case presentationIn this case report, we present a 61-year-old African American female patient who presented with bilateral knee pseudoseptic arthritis in the setting of viscosupplementation. She presented 3 days after bilateral viscosupplementation injections with bilateral knee swelling, discomfort, and pain with micromotion. Her white blood cell count (WBC) was 12.83 (4.5–11 normal), her C-reactive protein (CRP) level was 159 mg/L (0–10 normal), and her erythrocyte sedimentation rate (ESR) was 79 mm/hour (0–40 normal). Her left knee aspirate yielded 38,580 WBC with a negative gram stain and negative cultures. Her right knee aspirate yielded 29,670 WBC with a negative gram stain and negative cultures. Through the utilization of careful clinical monitoring, ice therapy, and non-steroidal inflammatory medication, we were able to successfully treat this patient while maintaining proper antibiotic stewardship.ConclusionPseudoseptic arthritis in the setting of viscosupplementation can be adequately treated and monitored without the use of antibiotics.

An unusual case of trichotillomania and trichophagia associated with authentic hair extension as seen in a young African-American female adult

Trichotillomania refers to repetitive pulling of hair from the body and may be accompanied by trichophagia, the ingesting of extracted hair. It is frequently comorbid with other psychiatric disorders and resulting hair loss can seriously affect quality of life. Trichophagia can lead to trichobezoars, indigestible aggregations of hair in the gastrointestinal tract that can cause pain and bowel obstruction. Descriptions of trichotillomania and trichophagia have generally assumed European hair texture and styling conventions with little attention to Black hair. Here we report the case of a 23-year-old African-American female patient that presented with a small bowel obstruction from ingestion of hair extracted from a hair weave, a popular styling practice and form of hair extension frequently used with women of African descent and various ethnic groups.

A Case of Primary Dural Lymphoma Treated with Bendamustine and Rituxan

Background Primary CNS lymphoma (PCNSL) is an aggressive form of extranodal non-Hodgkin lymphoma that arises in the brain parenchyma, eyes, meninges, or spinal cord in the absence of systemic disease. Primary dural lymphoma (PDL) arises from the dura mater of the brain. It differs biologically from other CNS lymphomas. It is usually a low-grade B-cell marginal zone lymphoma (MZL), whereas other types of PCNSL are usually high-grade large B-cell lymphoma. This specific pathological subtype has important therapeutic and prognostic implications, making PDL a distinct subtype of PCNSL. Herein, we report a case of PDL in an African American patient who was treated with bendamustine and rituximab. Case Presentation A 38-year-old African American female patient presented with chronic intermittent headaches. MRI of the brain showed a dural-based homogeneously enhancing extra-axial mass along the left hemisphere with extension to the anterior interhemispheric falx and anterior right frontal lobe measuring up to 11 cm. This was found to have a significant mass effect and 1-2 cm left-to-right midline shift on the underlying brain parenchyma with vasogenic edema. The patient underwent an emergent craniotomy and debulking of the mass. The tumor was contained within the anterior and parietal dural matter. The malignant cells stained diffusely positive for CD19, CD20, and CD22 but negative for CD5, CD10, Cyclin D1, and CD56. Ki67 was 10-20%, consistent with extranodal marginal zone lymphoma. Given the location and pathology, the patient was diagnosed with PDL. She was started on treatment with bendamustine and rituximab. She completed six cycles, and post-therapy MRI brain showed complete remission. She continues to do well two years after finishing treatment. Discussion The Dura mater is devoid of lymphoid tissue; however, it is hypothesized that chronic inflammation of the dura due to chronic infection or autoimmune disorder may attract polyclonal lymphocytes from which monoclonal lymphoma could arise. PDL has not been definitively associated with any infectious or autoimmune disease, but patients with hepatitis C, scleroderma, Graves' disease, and Sjogren disease have been reported. Developmentally, the dura originates from the mesoderm. In contrast, the CNS originates from the ectoderm, which leads to the presence of the dura outside the blood-brain barrier and is easily exposed to systemic therapies. So, HDMTX regimens are excessive for PDL, where MZL is the most common pathology. Because of this and the known efficacy of bendamustine-rituximab in extranodal MZL, we decided to treat our patient with this regimen. Tsutsumi et al. reported 2 cases of dural MZL that were treated successfully with bendamustine-rituximab. However, those two cases also had evidence of systemic disease, not only dural disease like our patient. Because of its indolent pathology, surgery and/or radiation have also been used as treatment modalities, although complete resection of dural lymphomas can be technically difficult Conclusion Our case adds to the sparse literature about primary dural lymphoma. It emphasizes the importance of recognizing it as a separate entity from parenchymal PCNSL, an aggressive disease with a poor prognosis. Surgery, radiation, and/or chemoimmunotherapy used for other extranodal MZL are appropriate treatments for PDL. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Diabetic ketoacidosis and coronavirus disease 2019-associated mucormycosis: a case report

BackgroundMucormycosis is a rare, life-threatening fungal infection that affects immunocompromised hosts. Diabetes mellitus is a common predisposing condition and most often presents with rhino-orbital-cerebral infection. Association with coronavirus disease 2019 infection was revealed following a resurgence in cases of mucormycosis during the second wave of the pandemic wherein poorly controlled diabetes mellitus was the most significant risk factor in the affected population. Rhino-orbital-cerebral mucormycosis has a high mortality rate, and cerebral involvement is a poor prognostic factor. Herein, we report a case of newly diagnosed diabetes mellitus with concurrent coronavirus disease 2019 infection complicated by diabetic ketoacidosis and rhinocerebral mucormycosis at presentation, describe the diagnostic and therapeutic challenges, and discuss the interventions that ultimately resulted in a favorable clinical response.Case presentationWe describe the case of a previously healthy 13-year-old African American female patient with newly diagnosed diabetes mellitus and concurrent severe acute respiratory syndrome coronavirus 2 infection whose disease course was complicated by rhinocerebral mucormycosis. She presented with fever, altered mental status, and Kussmaul respirations and was diagnosed with diabetic ketoacidosis with concern for cerebral edema. Concern for infectious cerebritis arose due to recurring fevers and persistently altered mental status despite correction of her metabolic derangements. This raised concern for infectious cerebritis and prompted evaluation with serial head imaging, lumbar puncture, and initiation of broad empiric antimicrobial regimen. Head imaging revealed an evolving cerebral abscess, and fungal deoxyribonucleic acid was identified on blood metagenomics testing, which ultimately confirmed the diagnosis of rhinocerebral mucormycosis. Treatment was challenging as she required surgical debridement of the frontal lobe and aggressive antifungal therapy complicated by electrolyte derangements and electrocardiogram changes that necessitated modification of the antimicrobial regimen. Despite these challenges and high mortality rate, the patient was discharged from the hospital in stable condition to inpatient rehabilitation service for reconditioning after prolonged hospitalization.ConclusionRhinocerebral mucormycosis mortality is associated with delays in therapeutic interventions, thus a high index of suspicion and early recognition were essential for timely initiation of antifungal therapy and surgical debridement.

The association between adult-onset Still’s disease and collapsing glomerulopathy: a case report

BackgroundCollapsing glomerulopathy, characterized by marked hypertrophy and hyperplasia of the podocytes with eventual collapse of the glomerular tuft, is an important cause of end-stage renal disease. Among the many causes of collapsing glomerulopathy, autoimmune diseases, such as systemic lupus erythematosus, have been implicated. There are also rare reports of adult-onset Still’s disease, an autoinflammatory condition characterized by fever, rash, and inflammatory arthritis being associated with collapsing glomerulopathy.Case presentationHerein, we present a review of three published cases, and present a new case of a 15-year-old African American female patient with collapsing glomerulopathy who was diagnosed with adult-onset Still’s disease 12 years later when she presented with fevers, arthralgias, sore throat, lymphadenopathy, hepatocellular injury, and elevated serum ferritin. Her collapsing glomerulopathy was initially well controlled following induction therapy with cyclosporine and prednisone and maintenance therapy with losartan. However, after developing adult-onset Still’s disease, she had multiple flare-ups despite various immunosuppressive therapies and developed worsening renal function, eventually progressing to end-stage renal disease.ConclusionsOur case-based review highlights a rare but important association between adult-onset Still’s disease and collapsing glomerulopathy, and postulates a possible pathophysiological link.

Moyamoya Disease in a Young Female With Neurofibromatosis Type 1

Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive stenosis of the terminal portions of the internal carotid arteries (ICAs) and the development of a network of abnormal collateral vessels. This case depicts a 25-year-old African American female patient with neurofibromatosis type 1 (NF-1), whose initial hospital presentation occurred in a hypertensive emergency setting. Surveillance studies with magnetic resonance imaging (MRI) revealed multiple asymptomatic right cortical strokes. Genetic testing evidenced a novel, unique pathogenic variant on the NF-1 gene. The patient underwent combined bypass surgery first and then was placed on aspirin and a blood pressure control regimen. Our case illustrates the need for clinicians to include moyamoya disease in the list of differential diagnoses when encountering a young patient, without major risk factors, presenting with ischemic stroke. It should be considered even with no known history of previously diagnosed MMD or NF-1, as these pathologies may have yet to be evaluated in subclinical cases.

Asymptomatic Hypercalcemia and Acute Kidney Injury as Presenting Manifestation of Sarcoidosis: A Case Report

Acute renal failure is rarely associated with the usual presentations of sarcoidosis. Sarcoidosis is associated with hypercalcemia and presents with granulomas within other organs, usually the lungs [1]. We present a case of acute renal failure with hypercalcemia in an African American female patient who was eventually diagnosed with sarcoidosis.

RADIOGRAPHIC FEATURES OF INTERCRESTAL AND CLASSIC OSTEOSARCOMA: A REPORT OF 3 CASES

<h3>BACKGROUND</h3> With this poster we add 2 new cases of intercrestal osteosarcoma to the 2 cases reported at the 2017 AAOMR annual meeting in the poster entitled, "Osteosarcoma: A Report of Two Cases With Similar Radiographic Features." One of the present intercrestal cases was clinically thought to be a "gingival epulis." These 2 additional cases serve to raise awareness of the importance of recognizing the radiographic features of osteosarcoma occurring in an intercrestal location. In addition, we present another case of osteosarcoma with the classical features of sunburst bone pattern, knife-edge root resorption, and periodontal ligament (PDL) widening. With these cases and the authors' own experience it is certainly true that osteosarcoma is the most common primary malignant bone tumor of the jaws.¹ <h3>CASE REPORT</h3> Intercrestal case 1: A young male patient presented with clinical swelling in the area of teeth #26 and #27. A panoramic radiograph revealed unilateral PDL widening on teeth #26 and #27 and displacement of these teeth. There was growth of the intercrestal bone and a patchy sclerotic nature to the interradicular bone pattern. Intercrestal case 2: A 63-year-old white female patient presented with a gingival nodule of 2 months' duration. Periapical and panoramic radiographs revealed PDL widening along tooth #21, displacement of teeth #20 and #21, growth of the intercrestal bone, and subtle radiolucent and radiopaque changes in the interradicular bone. Classical osteosarcoma case: A 53-year-old African American female patient presented with an expansile 2 × 2 cm firm, painful lesion associated with the mandibular left second molar. Panoramic and cone beam computed tomography images revealed a radiopaque bone pattern, PDL widening, tooth displacement, spiked root resorption, and sunburst bone pattern. <h3>DISCUSSION/CONCLUSIONS</h3> Intercrestal osteosarcoma may be a subtle relative of the expansion associated with the classic sunburst pattern. Meticulous attention to details is crucial during radiographic evaluation.

Diffuse Gonococcal Infection (DGI) in a Patient with Treatment-Refractory Acetylcholine Receptor Antibody-Positive (AChR+) Generalized Myasthenia Gravis (gMG) Treated with Eculizumab

Patients receiving complement inhibitor, eculizumab, are at high risk for infections with encapsulated organisms such as Neisseria due to impaired opsonophagocytic activity. Impaired complement immunity may increase the risk for dissemination of asymptomatic Neisseria gonorrhoeae. Disseminated Gonococcal Infection (DGI) is a rare but potentially life-threatening complication associated with eculizumab. Physicians should obtain adequate sexual histories from the patients and educate them on safe sexual practices. Here, we describe a case of DGI in a 32-year-old African American female patient with acetylcholine receptor antibody-positive (AChR+) generalized myasthenia gravis (gMG), receiving eculizumab.

The Impact of Lymphedema Therapy on Quality of Life: A Case Report

Background and Purpose: Lymphedema is a chronic inflammatory lymphostatic disease known as the buildup of lymph fluid in the fatty tissues that can cause swelling and discomfort in the arms, legs, face, neck, trunk, abdomen, and genitals [1]. Failure of the lymphatic system causes lymphedema [1]. Lymphedema may reduce the quality of life and may progress as well as cause other complications such as cellulitis if untreated [1]. Although there is no cure for lymphedema, there are interventions to reduce or manage the swelling and the discomfort [1]. The purpose of this study is to show that a patient with lymphedema can improve their quality of life significantly with adequate lymphedema therapy interventions using Complete Decongestive Therapy (CDT). Method and Procedures: A 47-year-old African American female patient presented to outpatient physical therapy with a report of experiencing bilateral lower extremity swelling for about ten years. To determine the effects of the treatments, the lymphedema therapist examined the patient using the following tests and measures and outcome measurement tools: Bilateral Girth Measurements, the Lymphedema Life Impact Scale Version 2 (v2), and the Global Rating of Change (GRoC) Scale. The patient attended physical therapy sessions 2 times per week for 3 weeks not including the date of initial evaluation. Thus, the patient attended five treatment sessions. The patient actively participated in the creation of the current goal: to decrease bilateral lower extremity swelling. Results: On discharge assessment (6th visit), the patient reported a reduction in pain to (3/10). The patient scored a 12/68 on the Lymphedema Life Impact Scale (v2) indicating that her quality of life had improved significantly within the past three weeks since receiving lymphedema therapy services. The patient made excellent progress, demonstrated marked improvements with involved extremities lymphatic circulation, and decreased swelling with girth measurements. The patient reported significant improvements with functional activities of daily living such as standing, sitting to standing, and walking. The patient also reported that her quality of life improved significantly.

15427 Gradle scissor removal of an epidermal nevus in a 13-year-old girl

A 13-year-old African-American female patient presented for a large epidermal nevus of her right shoulder and right axilla to our clinic. It had never been treated before and she had no history of hypertrophic scars or keloids. The lesion was extremely irritating with movement in the axillary body fold, becomingly increasingly malodorous, and cosmetically bothersome to the patient. The most medial aspect of the lesion was encroaching on the lateral edge of her breast tissue. The patient and her mother desired removal of the lesion and were very concerned about scarring especially due to the proximity to the developing breast.

Histoplasmosis Diseminada en paciente Inmunocompetentes

La histoplasmosis es una infección micótica que se adquiere por inhalación causando enfermedad pulmonar en su forma primaria. Puede diseminarse a otros órganos sobre todo en pacientes inmunodeprimidos en quienes alcanza una alta mortalidad. Es endémica en ciertas zonas, en especial las templadas y tropicales. Las manifestaciones clínicas varían según la diseminación y estado inmunológico de la persona. El diagnóstico se lo realiza por la identificación histopatológica, cultivo y serología.&#x0D; Paciente femenina adulta joven afroamericana sin antecedentes clínicos que presenta cuadro de un año de evolución caracterizado por pérdida involuntaria de peso, alopecia, lesiones dérmicas hiperpigmentadas, diarrea y adenopatías cervicales cuyo estudio histopatológico fue compatible con histoplasmosis. Estudios de extensión sugirieron, pero no confirmaron, una patología autoinmune asociada.&#x0D; En Ecuador no existe registro de casos de histoplasmosis a pesar de ser considerada una micosis endémica en la zona. El estudio de inmunocompetencia en el caso presente fue sugestivo de un lupus eritematoso sistémico con manifestaciones solapadas. Los pacientes con Lupus Eritematoso Sistémico son susceptibles a infecciones oportunistas por hongos dado a defectos inmunológicos intrínsecos con alteración de la inmunidad celular.&#x0D; La histoplasmosis es una enfermedad endémica en nuestro medio, infradiagnosticada por la diversidad del cuadro clínico y su asociación con otras patologías.

A Challenging Diagnosis of Leg Ulcer.

Ischaemic ulcers of the lower limb can have several aethiopathological mechanisms. For instance, the uncommon Martorell hypertensive leg ulcer is an infrequent complication of long-term uncontrolled arterial hypertension and is largely ignored and underdiagnosed. The typical ulcer is on the lower leg, is extremely painful and presents in female patients over 60 years of age with cardiovascular risk factors, mainly severe arterial hypertension. The diagnosis is histological, with obliteration of the arterioles by arteriolosclerosis. In these cases, antihypertensive medication is the standard treatment. We describe the case of an African-American female patient with long-term hypertension who presented with a very painful leg ulcer. The diagnosis was complicated by the coexistence of more common causes of ulcer. Despite analgesic medicines, pain relief was only obtained with control of hypertension. A definite diagnosis was made following biopsy.In describing this diagnosis of an ischaemic leg ulcer, we highlight the need to consider the skin as a target organ of arterial hypertension.LEARNING POINTSMartorell hypertensive leg ulcer is an underdiagnosed cutaneous lesion arising from long-term uncontrolled hypertension.The diagnosis is confirmed by histopathology.Standard treatment is adequate control of blood pressure.

P051 Low-level antibody against shared epitopes – are they relevant?

This case illustrates the importance of considering low-level antibody reactivity against HLA shared epitopes. A 58 year African American female patient with ESDR due to DM type 2 was evaluated for simultaneous kidney-pancreas transplantation. Although the patient had 4 pregnancies, based on the One Lambda Single Antigen (SA) results, the patient had only weak ( ∼ 500 MFI. To investigate this discrepancy, phenotype bead assay (LSPRA) was performed, which clearly detected the presence of weak antibodies against A2, A68, and A69, which are known to share an epitope 144TKH (Figure 1B). Reactivity against A2 was additionally confirmed using surrogate crossmatches. We concluded that due to epitope sharing the single antigen bead assays may not have reflected the true strength of the patient’s antibodies and listed A2, A68, and A69 as unacceptable antigens in UNOS. The patient was successfully transplanted on 9/26/17 avoiding pre-existing DSAs. Interestingly, 10 days after transplant A2, A68, A69 increased to ∼ 20,000 MFI (Figure 1C). Since these specificities were not DSAs, no further action required. However, this case underscores that although low-level antibody against a shared epitope may not be effectively detected by solid-phase platforms, but still may result in positive crossmatch and increase the risk of AMR post-transplant. This case shows that setting positive cut-offs solely based on MFI values may be misleading if a patient has antibody against shared epitopes and that any discrepancy between virtual and cell-based crossmatch needs to be investigated. This case also highlights that use of epitope analysis and multiple assays help to evaluate immunological risk post-transplant more accurately.

Recognizing Skin Popping Scars: A Complication of Illicit Drug Use

“Skin popping” is a method of injecting illicit drugs into the skin. There are numerous acute and chronic complications associated with skin popping. We present a case of a 48-year-old, African-American female patient with 40 - 60 hyperpigmented, fibrotic, depressed, round papules and plaques on the extremities, which were incidentally noticed during a clinic visit for her acne vulgaris. Skin popping scars are important clues for possible drug abuse. Healthcare practitioners should be aware of and recognize the lesions associated with this practice so further testing can be performed if clinically indicated. Recognition of the lesions and thus earlier treatment of the complications could prevent the complications of skin popping in the skin and other organs.

A rare case of avascular necrosis in sickle cell trait: a case report

BackgroundSickle cell trait is usually an asymptomatic presentation of a patient with slightly different hemoglobin molecule makeup than normal. It is similar to a more serious disease, sickle cell disease, in which a person’s hemoglobin is mutated in such a way that causes their red blood cells to easily change shape in certain environmental and internal states; this causes red blood cells to adhere to the walls and occlude the lumen of the arteries in which they travel, leading to downstream effects secondary to ischemia. Sickle cell trait does not have these ischemic effects, usually.Case presentationIn this case, a young African American female patient presents to the clinic with severe right hip pain. Her past medical history includes sickle cell trait and asthma. She has not been symptomatic of her asthma for years and is not on therapy for it. The pain has lasted for several months and has not improved with anti-inflammatory medication. There is severe pain with internal and external rotation of the hip. The neurovascularity of the lower extremities is intact bilaterally. MRI of the femur shows stage 2 or 3 avascular necrosis of the femoral head, while X-rays of the femur are unremarkable. Non weight-bearing for several weeks was unsuccessful; shortly thereafter, the patient underwent core decompression of the right femoral head as well as starting bisphosphonates. The patient improved temporarily but regressed shortly thereafter. Her avascular necrosis worsened radiographically over the next several months. At this point, the only other option would be to do a total hip arthroplasty, but the patient may need several more throughout her lifetime due to the lifespan of the artificial replacement.ConclusionThere have only been scarce reports of avascular necrosis in patients with sickle cell trait. This manuscript presents such a case and includes the trials and tribulations associated with its management.

Multimodality Imaging of Rare Adult Presentation of ALCAPA Treated With Takeuchi Repair

A 17-year-old African-American female patient was referred to our institution to evaluate an incidentally diagnosed murmur. She lacked stigmata of chronic illness and had no abnormalities on examination other than a flow murmur at the left and right upper sternal borders. She had occasional sharp,

Objective Burn Assessment Using Laser Doppler Imaging and Indocyanine Green Videoangiography to Evaluate the Effect of Hyperbaric Oxygen Treatment: A Case Report

Introduction: Several relatively new technologies have served as valuable adjuncts to clinical judgment in burn wound depth assessment. Among these technologies, laser Doppler imaging and indocyanine green videoangiography have improved accuracy of burn depth assessment. However, an objective way to monitor improvement and changes in blood flow after hyperbaric oxygen treatment is not well documented. Methods: We present a case of a 43 year-old African American female patient whose burns we evaluated with laser Doppler imaging and indocyanine green videoangiography prior to and after hyperbaric oxygen therapy (HBOT). Results: These imaging modalities documented an improvement in perfusion of the burned tissues in our patient. Conclusions: Though we need more comparative data in the form of prospective studies with large cohorts to make concrete recommendations, we suggest with our case report that laser Doppler imaging and indocyanine green videoangiography can be used to monitor improvement and document blood flow after HBOT.

Management of Vaccination Failure in a Case of HIV -HBV Co-infection: A Case Report

Background: A 60-year-old African American female patient, with chronic HIV infection since 1999, presented with markers of acute hepatities B virus (HBV) infection for the past 15 months. The patient was previously vaccinated for HBV. Immunoglobulin dysfunction was hypothesized, but electrophoresis yielded no conclusive result. Results: Investigation suggests that the patient is a non-responder: someone who fails to sero-convert to standard vaccinations. This condition can be linked to B-cell dysfunction due to chronic HIV infection. Conclusion: It is suggested that non-responders may require a 6-dose regimen to achieve sero-conversion for vaccination. Prevention of co-infection should be the mainstay of treatment, which is achieved by vaccination. However, immune system dysfunction can lead to complications.

Breast Lesions with Intractable Pain in End-Stage Renal Disease: Calciphylaxis with Chronic Hypotensive Dermatopathy Related Watershed Breast Lesions

There are very few reports about end-stage renal disease (ESRD) patients with breast pains in the medical literature, posing a difficulty to understand their pathophysiology. A 47-year-old African American female patient with ESRD on hemodialysis presented to the pain clinic with new-onset black maculopapular skin lesions on her breasts. These lesions started out as dark spots and then became necrosed, exposing the underlying tissue. The painful and tender lesions were located in a circumferential pattern around the bases of both breasts. She had stopped using breast supporting undergarments secondary to allodynia-hyperalgesia eliciting from necrotizing skin tissues. Her recent skin biopsy was inconclusive about ruling in or out the possibility of calciphylaxis. However, her past mammograms had showed calcium deposits in her breasts. Her other past medical history was significant for chronic hypotension with recently diagnosed legal blindness bilaterally. Her home medications included midodrine. The systolic blood pressures in either arm were consistently recorded in high 60s to low 70s during the interdialytic periods. She had multiple emergency room admissions secondary to persistent chronic hypotension; however the underlying pathophysiology for intractable but asymptomatic hypotension remained obscure. Over the course of the next 11 months her nonhealing breast lesions progressed and became infected. She developed septic shock due to infected lesions. Per her do-not-resuscitate requests, she died peacefully while under inhospital hospice care. Morbidity-mortality with calciphylaxis and chronic hypotension related tissue changes is high, and the breast lesions in ESRD patients require aggressive treatment for underlying inadequate oxygen delivery to these peripheral tissues.