Calciphylaxis in the absence of pathological skin lesions

A woman in her 40s with haemodialysis-dependent end-stage renal disease presented to our emergency department with severe bilateral lower extremity pain with erythema and oedema. Bedside ultrasound was inconclusive and further imaging was delayed due to significant patient discomfort during bed transfers. Ultimately, this patient was suspected to have calciphylaxis after a successful CT scan with premedication due to significant subcutaneous tissue calcification. Her diagnosis was confirmed with tissue punch biopsy. Her first pathological skin lesion presented at the biopsy site, and the patient subsequently experienced a protracted hospital course at two separate hospitals before passing away at home, approximately 3 months after the initial presentation. Our case demonstrates the heterogeneity of initial symptoms of calciphylaxis and the inherent risks of biopsy-dependent diagnostic confirmation of this disease.