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| CASE REPORT |
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| Year : 2020 | Volume
: 7
| Issue : 4 | Page : 438-440 |
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Gangrene of penis in a patient with chronic kidney disease on dialysis
Hussam Alzaarir1, Abdellah Rizziki1, Achraf Miry2, Adnane Benzirar1, Amal Bennani2, Omar El Mahi1
1 Department of Vascular Surgery, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
2 Department of Pathology, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| Date of Submission | 22-Feb-2020 |
| Date of Decision | 01-Mar-2020 |
| Date of Acceptance | 07-Mar-2020 |
| Date of Web Publication | 24-Dec-2020 |
Correspondence Address:
Hussam Alzaarir
Department of Vascular Surgery, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda
Morocco
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijves.ijves_18_20
Gangrene of the penis in patients with chronic kidney disease undergoing hemodialysis is a rare occurrence. Such patients often have associated comorbidities such as type II diabetes mellitus and systemic hypertension. These conditions accelerate the process of atherosclerosis, which, along with calcium deposition, causes partial or complete obstruction of the blood vessel lumen, leading to ischemic necrosis at the tip of the penis. This adds to the preexisting morbidity and mortality in such patients. In most cases, appropriate medical management is advocated to prevent the deposition of calcium in the lumen.
Keywords: Calciphylaxis, diabetes mellitus, gangrene, hemodialysis
How to cite this article:
Alzaarir H, Rizziki A, Miry A, Benzirar A, Bennani A, El Mahi O. Gangrene of penis in a patient with chronic kidney disease on dialysis. Indian J Vasc Endovasc Surg 2020;7:438-40 |
How to cite this URL:
Alzaarir H, Rizziki A, Miry A, Benzirar A, Bennani A, El Mahi O. Gangrene of penis in a patient with chronic kidney disease on dialysis. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jan 16];7:438-40. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/438/304629 |
| Introduction | |  |
Calciphylaxis is a condition seen in 1%–4% of patients with end-stage renal disease on hemodialysis. It affects smaller arteries, arterioles, and capillaries.[1]
This condition is often associated with elevated calcium and phosphate.[1]
The penis is characterized by a rich vascular network, which make this organ rarely affected by the calciphylaxis. Penile calciphylaxis is a sign of poor prognosis with a mortality rate of 64%.[1],[2] Penectomy as treatment is still under debate.
In our work, we report the case of hemodialysis-dependent diabetic patient, with a history of bilateral inferior limb amputation, who presented with distal penile dry gangrene due to penile calciphylaxis along with three finger gangrene.
| Case Report | | |
We report the case of a 68-year-old male with a history of end-stage renal treated with hemodialysis for 2 years and poorly controlled type II diabetes mellitus treated with insulin for 20 years along with aspirin at preventive dose. The patient had also a history of critical ischemia of the two lower limbs, treated by transfemoral amputation. He had no history of hypertension.
The patient presented to the emergency room for distal penile dry gangrene.
Dry gangrene was also present in three distal fingers [Figure 1] and [Figure 2]. | Figure 1: Dry penile gangrene affected the two distal thirds of the glans
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 | Figure 2: Extragenital gangrene locations were presented by three distal finger parts
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Serum phosphate was 55 mg/L, serum calcium was 83 mg/L, calcium-phosphate product was 0.66 mg2/L2, albumin was 24 g/L, and hemoglobin was 9.0%.
A pelvic computed tomography scan was performed, which shows numerous calcifications of the pelvic arteries [Figure 3].
An arteriography of the two upper limbs and the pelvis was performed, which showed severe diffuse vascular calcifications [Figure 4]. | Figure 3: Computer tomography scan with contrast showing numerous calcifications of the pelvic arteries (Arrows)
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 | Figure 4: Arteriography showed extensive calcification of the right hypogastric artery and its branches (arrow) and stenosis of the origin of the left hypogastric artery (arrow head)
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A penectomy and an amputation of the distal necrotic finger parts were performed.
Perioperative penile degloving showed extensive ischemic damage. After penectomy, a Foley probe was used.
The pathological report showed microcalcifications in the stroma and vascular wall consistent with calciphylaxis [Figure 5] and [Figure 6]. | Figure 5: Crophotography showing extensive necrosis of the penile mucosa (H and E; ×100)
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 | Figure 6: Microphotography showing important calcium deposits in vascular lumens. (H and E; ×200)
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| Discussion | | |
Penile calciphylaxis is a sign of poor prognosis reflecting an overall mortality rate of 64%.
The mean time to death after presenting this condition is about 2.5 months.[2]
Serum calcium and phosphorus exceeds the normal plasma solubility in patients with chronic renal failure under hemodialysis. This causes precipitation of calcium phosphate crystals in the arterial lumen and walls.[3],[4] The deposition of these crystals in the media causes reactive changes and intimal hyperplasia. The result is a rapid luminal narrowing, especially when diabetes is associated as in the case of our patient.[3],[4]
Histologically, calciphylaxis is characterized by medial calcification and intimal fibrosis of medium and small arteries. These are usually limited to the arterial system but can occur in other areas such as eye, viscera or skin.[3]
This condition can be due to cholesterol crystal embolism or diabetic microangiopathy.[5]
Clinically, a mottling of the skin and livedo reticularis is a characteristic. The most affected body parts are distal extremities, buttocks, and thighs, and sometimes the penis.
The clinical findings are most often sufficient for diagnosis, explaining the nonnecessity of diagnostic penile biopsy, as recommended by Cimmino andCostabile.[6]
When this condition is isolated, clinical suspicion of melanoma must be present, which most commonly presents at the glans as a hyperpigmented irregular lesion.[7]
In the English literature, 51 cases of penile calciphylaxis have been reported.[8]
In a study about fifty cases of penile calciphylaxis in patients in end-stage renal disease, the average age was found to be 54.5 years.
Diabetes mellitus was found in 41 patients of the 50 cases of this series.[8]
The average calcium and phosphate levels were 9.2 mg/dl and 8.0 mg/dl, respectively.
The average calcium-phosphate product was 72.8–mg2/dl2.[8]
The median time to death was a month.
No correlations were found between mortality and factors including age, diabetes mellitus, calcium level, phosphate level, and calcium-phosphate product level.
In this same series, extragenital gangrene was noted in 32 patients. Extragenital gangrene involves more blood vessels and may result in a worse prognosis. This can explain the fact that observed mortality is higher when extragenital gangrene is associated.[8]
There was no statistically significant difference in survival between patients treated with penectomy and those treated with local debridement, as shown in a study by Karpman et al.[2]
Penile calciphylaxis can also be treated by other methods, as shown by Akai et al. with the femoral artery to deep dorsal penile vein bypass,[9] or by Sarkis T et al. with internal iliac artery balloon-expandable bare-metal stent implantation.[12]
Other therapeutic attempts using hyperbaric oxygen (in two cases) were performed but with no success.[11],[12]
Three cases were treated with sodium thiosulfate, and two patients survived.[10],[13],[14] The possible mechanism of sodium thiosulfate is the chelation of calcium ions, dissolution of insoluble calcium deposits, and restoration of the endothelium.[10]
In a retrospective study of 27 patients with calciphylaxis in other locations, 52% had been resolved using sodium thiosulfate.[2] This molecule acts by chelation of calcium ions which can end by dissolution of insoluble calcium deposits.[12]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Vedvyas C, Winterfield LS, Vleugels RA. Calciphylaxis: A systematic review of existing and emerging therapies. J Am Acad Dermatol 2012;67:e253-60.  |
| 2. | Karpman E, Das S, Kurzrock EA. Penile calciphylaxis: Analysis of risk factors and mortality. J Urol 2003;169:2206-9. |
| 3. | Kleeman CR, Massry SG, Coburn JW, Popovtzer MM. The problem and unanswered questions. Renal osteodystrophy, soft tissue calcification, and distrubed divalent ion metabolism in chronic renal failure. Arch Intern Med 1969;124:262-8. |
| 4. | Lowe FC, Brendler CB. Penile gangrene: A complication of secondary hyperparathyroidism from chronic renal failure. J Urol 1984;132:1189-91. |
| 5. | Bappa A, Hakim F, Ahmad M, Assirri A. Penile gangrene due to calcific uremic arteriopathy. Ann Afr Med 2011;10:181-4. [ PUBMED] [Full text] |
| 6. | Cimmino CB, Costabile RA. Biopsy is contraindicated in the management of penile calciphylaxis. J Sex Med 2014;11:2611-7. |
| 7. | Cherukumudi A, Hegde S, Rajeev TP, Pai N, Kumar A, Kalra G. Rare case of gangrene of penis in a patient with chronic kidney disease on dialysis. Urol Case Rep 2019;25:10090-1. |
| 8. | Yang TY, Wang TY, Chen M, Sun FJ, Chiu AW, Chen YH. Penile calciphylaxis in a patient with end-stage renal disease: A case report and review of the literature. Open Med (Wars) 2018;13:158-63. |
| 9. | Akai A, Okamoto H, Shigematsu K, Miyata T, Watanabe T. Revascularization surgery for penile calciphylaxis. J Vasc Surg 2013;58:1665-7. |
| 10. | Sarkis E. Penile and generalised calciphylaxis in peritoneal dialysis. BMJ Case Rep 2015;2015. pii: bcr2014209153. |
| 11. | Jacobsohn HA, Jenkins PG, Jacobsohn KM. Penile calciphylaxis. Urology 2002;60:344. |
| 12. | Oikawa S, Osajima A, Tamura M, Murata K, Yasuda H, Anai H, et al. Development of proximal calciphylaxis with penile involvement after parathyroidectomy in a patient on hemodialysis. Intern Med 2004;43:63-8. |
| 13. | Sandhu G, Gini MB, Ranade A, Djebali D, Smith S. Penile calciphylaxis: A life-threatening condition successfully treated with sodium thiosulfate. Am J Ther 2012;19:e66-8. |
| 14. | Morrison M, Merati M, Ramirez J, Cha HC, LaFond A. Penile calciphylaxis diagnosed with computed tomography. J Eur Acad Dermatol Venereol 2016;30:352-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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