Ischemic Ulcerations of Skin and Necrosis of Muscle in Azotemic Hyperparathyroidism

Abstract

Two women, 29 and 36 years old, with hyperparathyroidism due to chronic renal failure had extensive medial calcification and fibrous intimal proliferation of the small arteries of subcutaneous tissue and skeletal muscle. Both patients had severe necrosis of the skin of buttocks and lower extremities, often originating in localized areas of livedo reticularis. As skin lesions developed the first patient's fingertips became gangrenous, and the second patient experienced severe proximal myopathy with myoglobinuria. In the second patient skin and muscle damage occurred 3 months after kidney transplantation in the presence of moderately severe renal insufficiency. Plasma calcium, high after transplantation, became transiently normal as skin and muscle lesions became apparent. Plasma parathyroid hormone level, measured by radioimmunoassay before transplantation, was extremely high but slowly diminished after transplantation. It was concluded that in both patients skin and muscle lesions were a direct consequence of ischemia due to intimal proliferation in small arteries and ultimately were complications of hyperparathyroidism.