Clinical Review & Education JAMA Surgery Clinical Challenge Jane H. Kim, PhD; Stephen Somach, MD; Christopher R. McHenry, MD A D E B C Figure 1. Photographs of necrosis and eschar formation involving fingers (A), right (B) and left (C) toes, left posterior medial calf (D), and violaceous skin with central eschar on the posterior medial aspect of the right leg (E). A 52-year-old man with type 2 diabetes mellitus and end-stage renal disease presented with painful and progressive cutaneous necrosis of his fingers, toes, and calves and gener- WHAT IS THE DIAGNOSIS? alized muscle weakness with difficulty getting out of bed and walking. He had undergone hemodialysis for the past year and had a brachiocephalic fistula in his left arm. His medical A. Subacute bacterial endocarditis history was also significant for peripheral vascular disease, hypertension, and antiphospho- lipid antibody syndrome for which he was receiving warfarin sodium since 2010. His other B. Warfarin-induced skin necrosis medications were epoetin alpha, ferrous gluconate, cinacalcet hydrochloride, paricalcitol, sevelamer carbonate, amlodipine besylate, labetalol hydrochloride, lisinopril, simvastatin, C. Calcific uremic arteriolopathy pentoxifylline, and Humalog and Lantus insulin. He did not smoke. The patient had a temperature of 37.6°C and a grade II/VI systolic
JAMA Surgery – American Medical Association
Published: Feb 1, 2014
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