A 55 year old African American female with chronic renal failure presented with these skin lesions for 5 months. These extremely painful lesions initially started on her legs as violaceous mottling and then progressed to the present size and extended to her arms with greenish discharge. These lesions were excruciatingly tender and extremely firm on examination. Peripheral pulses were intact in all four extremities. She had used multiple courses of antibiotics with no relief.

Review of the patient's medical record revealed a history of hyperphosphatemia with hyperparathyroidism and hypoalbuminemia. At this visit she had a total WBC count of 11,000 with 65% neutrophils, BUN 45 mg/dl, Cr 3.1mg/dl, Ca 11.3 mg/dl, Ionized Ca 6.2 mg/dl, Phosphorus 6.2 mg/dl, Intact PTH 544 pg/ml.

Medical management with phosphate binders, aggressive wound care and debridement was unsuccessful and patient underwent total parathyroidectomy with partial resolution of symptoms in 3 months.