Recurrent Calciphylaxis With Discordant Parathyroid Hormone Trajectory in a Patient With HIV-Associated End-Stage Renal Disease: A Case Report

Calciphylaxis, also termed calcific uremic arteriolopathy, is a rare and devastating complication of end-stage renal disease (ESRD). Its occurrence in patients with HIV-associated ESRD is sparsely characterized in the literature. We report a 36-year-old African American woman with ESRD secondary to longstanding hypertension and virologically suppressed HIV infection (CD4 count 348 cells/μL) who developed three discrete presentations of recurrent calciphylaxis over 18 months, with histopathologic confirmation at initial diagnosis and at first recurrence. At initial presentation (T1), intact parathyroid hormone (iPTH) was 806.5 pg/mL; she was treated with paricalcitol, sevelamer carbonate, and intravenous sodium thiosulfate (STS) but remained intermittently nonadherent to hemodialysis and prescribed therapies, with a single-pool Kt/V of 0.29 documented at recurrence. At second presentation 12 months later (T2), iPTH was 308.4 pg/mL despite active cutaneous lesions; management included surgical debridement, broad-spectrum antibiotics for superimposed polymicrobial soft tissue infection, continued STS, and dialysis intensification. Six months after T2 (T3), the patient represented with lesion expansion and new ulcerations, and iPTH had risen to 1,764.9 pg/mL alongside hypocalcemia and hyperphosphatemia, consistent with progression toward tertiary hyperparathyroidism. Parathyroidectomy was deferred at T2 and T3 because of acute infectious burden and uncontrolled hyperkalemia, respectively. This case illustrates the diagnostic and management complexity of recurrent calciphylaxis in HIV-associated ESRD, demonstrates how intermittent treatment adherence may produce highly discordant iPTH measurements that complicate threshold-based monitoring, and underscores the importance of multidisciplinary planning before surgical and metabolic barriers to parathyroidectomy accumulate.