Painless Scrotal Ulcers Become Something Unexpected: A Rare Case of Scrotal Calciphylaxis.

Calciphylaxis is an uncommon vascular disorder that presents with painful skin necrosis due to calcium accumulation in the skin and adipose tissue. It often presents in patients with multiple comorbidities like end-stage renal disease (ESRD) and in patients who are on long-term dialysis. This case highlights the atypical presentation of painless ulceration as seen in our patient. A 68-year-old Caucasian male with a past medical history of ESRD on hemodialysis (HD), diabetes mellitus II, and peripheral vascular disease presented to the hospital with altered mental status and severe left foot necrosis. During the hospital course, the patient developed a painless scrotal wound and eschar with sloughing. The ulcer was non-tender to palpation. Ultrasound identified calcifications in the scrotal tissue and CT of the pelvis without contrast showed extensive calcification of the arterial system. A clinical diagnosis of calciphylaxis was made. Treatment was initiated with sodium thiosulfate. The patient stabilized over the next few days; however, a few days later, the patient was readmitted and unfortunately passed away due to cardiac arrest. This case delineates the atypical presentation of calciphylaxis. Although painful skin necrosis is a well-reported and classic presentation of this disease, the lack of pain perception despite such a severe condition in our patient is of particular interest. This case calls for a closer look into the diagnosis of calciphylaxis, especially in the presence of nontender skin ulcers. This diagnosis should be part of the differential in a patient with ESRD on HD even when the presentation is atypical as early diagnosis and intervention can prevent fatal outcomes.