Combined therapy with sodium thiosulfate and parathyroidectomy in a patient with calciphylaxis

Calciphylaxis is a serious form of vascular calcification that leads to skin necrosis with ulceration. It usually occurs in dialysis patients and carries very high morbidity and mortality rates. We present the case of a dialysis patient with biopsy-proven calciphylaxis of the lower extremity and severe secondary hyperparathyroidism, who had been receiving outpatient sodium thiosulfate, with no improvement. For management of the severe hyperparathyroidism, the patient underwent surgical excision of the parathyroid glands, leading to rapid correction of parathyroid hormone (PTH) levels and the concomitant calcium and phosphorus abnormalities. Subsequently, she was continued on outpatient sodium thiosulfate on dialysis days, and follow-up demonstrated progressive resolution of the skin lesion. We believe that in dialysis patients with significant secondary hyperparathyroidism and calciphylaxis, the combination of sodium thiosulfate with medical or surgical correction of the metabolic disorder should be considered as the first-line management approach along with pain control and optimal wound care.