Penile Calciphylaxis: A Rare Complication in a Patient with ESKD

Introduction: Calciphylaxis, a rare but potentially devastating complication, predominantly affects patients with end-stage kidney disease (ESKD) undergoing dialysis, with a reported prevalence of 1-4%. Penile calciphylaxis is an even rarer manifestation, with limited data on its prevalence due to the scarcity of reported cases. This case further highlights the rarity of this presentation. Case Description: A 61-year-old male with a history of ESKD on hemodialysis since 2020, HTN, DM, and PAD s/p bilateral below-knee amputation presented with week-long urinary retention. Despite initial drainage of 800cc of urine with catheter placement, he developed phimosis, balanitis, and purulent discharge. A 14-day course of antibiotics for a urinary tract infection was completed, but symptoms persisted. A penile incision was performed, yet he continued to have penile pain and developed new-onset black discoloration of the glans penis. Computed tomography of the abdomen/pelvis showed surrounding soft tissue calcifications and gas within the corpora cavernosa and scrotum. Penectomy and urethrostomy were performed. Histopathological examination revealed extensive tissue necrosis, acute inflammatory infiltrates with abscess formation, and multifocal calcification involving medium-sized arteries. Laboratory evaluation showed parathyroid hormone at 372 pg/mL, with calcium levels in the 7-8 mg/dL range and phosphorus levels in the 3-4 mg/dL range. Albumin was 2.9 g/dL. No medications linked to calciphylaxis (phosphate binders, calcium supplements, warfarin, iron) were in use. Based on the findings suggestive of penile calciphylaxis, two doses of sodium thiosulfate 25g were administered. However, the treatment was discontinued due to concerns about prolonged QTc interval. Fortunately, on six-month follow-up, no new lesions or associated pain suggestive of calciphylaxis have developed. Discussion: This case highlights the diagnostic challenge of penile calciphylaxis in ESKD. Initial symptoms, such as those seen here, can mimic a UTI or represent superimposed infection, potentially delaying diagnosis of calciphylaxis. Maintaining high suspicion for calciphylaxis is crucial in ESKD patients with unexplained skin lesions and persistent pain despite treatment for other causes due to the high morbidity and mortality associated with the condition.