JAMA Clinical Challenge

Diffuse Calcification and a Draining Wound

Image of radiograph of the pelvis and hips

Sandeep M. Patel, MD
Todd D. Miller, MD
A 46-year-old man receiving chronic hemodialysis for polycystic kidney disease is admitted to the hospital with new-onset dyspnea and altered sensorium. He is noted to have “milky” secretions draining from a spontaneous eruption on his left thigh. His thigh is swollen; radiographs show bulky, extra-articular calcifications (Figure). A 3.4 x 2.3-cm mass involving the posterior mitral leaflet associated with moderate regurgitation is found with transesophageal echocardiography.

Mental confusion is readily apparent on physical examination. There is no fever or hemodynamic instability. He has jugular venous distension and an apical 5/6 holosystolic murmur. He also has bilateral inspiratory crackles, lower extremity edema, and bilateral shoulder and hip swelling. Initial laboratory evaluation shows leukocytosis (16.5x109 cells/L [reference range, 3.5-10.5]); increased levels of blood urea nitrogen (121 mg/dL [8- 24]), creatinine (7.1 mg/dL [0.8-1.3]), potassium (5.8 mmol/L [3.6-5.2]), and phosphorus (8.9 mg/dL [2.5-4.5]); and decreased levels of calcium (7.6 mg/dL [8.9-10.1]) and albumin (2.4 g/dL [3.5-5.0]).

Computed tomography of the head is unrevealing. A presumptive diagnosis of endocarditis is made, blood cultures are drawn, and broad-spectrum antibiotics are initiated.

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Author Affiliations: Drs Miller (miller.todd@mayo.edu) and Patel are affiliated with the Department of Internal Medicine (Dr Patel) and Division of Cardiovascular Diseases (Dr Miller), Mayo Clinic, Rochester, Minnesota; and the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Patel).