Breast lesions with intractable pain in end-stage renal disease: calciphylaxis with chronic hypotensive dermatopathy related watershed breast lesions.

BACKGROUND: There are very few reports about end-stage renal disease (ESRD) patients with breast pains in the medical literature, posing a difficulty to understand their pathophysiology.

CASE PRESENTATION: A 47-year-old African American female patient with ESRD on hemodialysis presented to the pain clinic with new-onset black maculopapular skin lesions on her breasts. These lesions started out as dark spots and then became necrosed, exposing the underlying tissue. The painful and tender lesions were located in a circumferential pattern around the bases of both breasts. She had stopped using breast supporting undergarments secondary to allodynia-hyperalgesia eliciting from necrotizing skin tissues. Her recent skin biopsy was inconclusive about ruling in or out the possibility of calciphylaxis. However, her past mammograms had showed calcium deposits in her breasts. Her other past medical history was significant for chronic hypotension with recently diagnosed legal blindness bilaterally. Her home medications included midodrine. The systolic blood pressures in either arm were consistently recorded in high 60s to low 70s during the interdialytic periods. She had multiple emergency room admissions secondary to persistent chronic hypotension; however the underlying pathophysiology for intractable but asymptomatic hypotension remained obscure. Over the course of the next 11 months her nonhealing breast lesions progressed and became infected. She developed septic shock due to infected lesions. Per her do-not-resuscitate requests, she died peacefully while under inhospital hospice care.

CONCLUSION: Morbidity-mortality with calciphylaxis and chronic hypotension related tissue changes is high, and the breast lesions in ESRD patients require aggressive treatment for underlying inadequate oxygen delivery to these peripheral tissues.