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      Warfarin-Induced Calciphylaxis in a COVID-19 Patient

      case-report
      Author(s): 1 , , 1 , 1 , 2
      Editor(s): ,
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Cureus
      Publisher: Cureus
      Keywords: calciphylaxis, warfarin, skin necrosis, covid-19, calcific uremic arteriolopathy, hypercoagulability, esrd

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          Abstract

          Calciphylaxis is a rare but highly fatal vascular calcification disorder with a predilection for patients with end stage renal disease (ESRD). The pathogenesis of calciphylaxis is unknown, however, several risk factors have been identified such as hypercalcemia, hyperphosphatemia, hyperparathyroidism, low serum albumin, and history of warfarin therapy. This article presents a case of calciphylaxis induced by warfarin in a COVID-19 patient.

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          Calciphylaxis

          Sagar Nigwekar, Vincent M Brandenburg, Julie Ingelfinger … (2018)
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            Calciphylaxis: natural history, risk factor analysis, and outcome.

            Mark D P Davis, Roger Weenig, T. G. McCarthy … (2007)
            Calciphylaxis is characterized by ischemic cutaneous ulceration, high mortality, and ineffective treatment. We conducted a retrospective study of 64 patients with calciphylaxis (including 49 dialysis patients age- and sex-matched to 98 dialysis controls). The estimated 1-year survival rate of calciphylaxis was 45.8%. Risk factors for calciphylaxis included obesity, liver disease, systemic corticosteroid use, calcium-phosphate product more than 70 mg(2)/dL(2), and serum aluminum greater than 25 ng/mL. Survival rates were similar for 16 patients who received parathyroidectomy and 47 who did not. An estimated 1-year survival rate of 61.6% was observed for 17 patients receiving surgical debridement compared with 27.4% for the 46 who did not (P = .008). The study was limited by its retrospective design and there was no control group for the 15 nondialysis cases. Calciphylaxis is multifactorial and usually fatal. Prevention of calciphylaxis may include correction of risk factors identified in this study. Surgical debridement was associated with improved survival, but parathyroidectomy was not.
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              A Nationally Representative Study of Calcific Uremic Arteriolopathy Risk Factors.

              Sagar Nigwekar, Sophia Zhao, Julia Wenger … (2016)
              Accurate identification of risk factors for calcific uremic arteriolopathy (CUA) is necessary to develop preventive strategies for this morbid disease. We investigated whether baseline factors recorded at hemodialysis initiation would identify patients at risk for future CUA in a matched case-control study using data from a large dialysis organization. Hemodialysis patients with newly diagnosed CUA (n=1030) between January 1, 2010, and December 31, 2014, were matched by age, sex, and race in a 1:2 ratio to hemodialysis patients without CUA (n=2060). Mean ages for patients and controls were 54 and 55 years, respectively; 67% of participants were women and 49% were white. Median duration between hemodialysis initiation and subsequent CUA development was 925 days (interquartile range, 273-2185 days). In multivariable conditional logistic regression analyses, diabetes mellitus; higher body mass index; higher levels of serum calcium, phosphorous, and parathyroid hormone; and nutritional vitamin D, cinacalcet, and warfarin treatments were associated with increased odds of subsequent CUA development. Compared with patients with diabetes receiving no insulin injections, those receiving insulin injections had a dose-response increase in the odds of CUA involving lower abdomen and/or upper thigh areas (odds ratio, 1.49; 95% confidence interval, 1.03 to 2.51 for one or two injections per day; odds ratio, 1.88; 95% confidence interval, 1.30 to 3.43 for 3 injections per day; odds ratio, 3.74; 95% confidence interval, 2.28 to 6.25 for more than three injections per day), suggesting a dose-effect relationship between recurrent skin trauma and CUA risk. The presence of risk factors months to years before CUA development observed in this study will direct the design of preventive strategies and inform CUA pathobiology.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 24 December 2020
                Publication date (Electronic, collection): December 2020
                Volume: 12
                Issue: 12
                Electronic Location Identifier: e12249
                Affiliations
                [1 ] Emergency, Imam Abdulrahman Bin Faisal University, Al Khobar, SAU
                [2 ] Pathology, Imam Abdulrahman Bin Faisal University, Al Khobar, SAU
                Author notes
                Article
                DOI: 10.7759/cureus.12249
                PMC ID: 7767840
                PubMed ID: 33391959
                SO-VID: 428ce85d-0e1b-4aab-acce-2016e454f673
                Copyright © Copyright © 2020, Abutaki et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date accepted : 23 December 2020
                Categories
                Subject: Emergency Medicine
                Subject: Internal Medicine
                Subject: Pathology

                Keywords: calciphylaxis,warfarin,skin necrosis,covid-19,calcific uremic arteriolopathy,hypercoagulability,esrd
                Data availability:
                Keywords: calciphylaxis, warfarin, skin necrosis, covid-19, calcific uremic arteriolopathy, hypercoagulability, esrd

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