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Clinical Research
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Maggot debridement therapy in the calciphylaxis patient: analysis of 4 cases Debra L. Miller-Cox, MD, Donna Hager, RN, CWOCN, Janet Powell, FNP, Cheryl Neese, RN, CWCN Calciphylaxis is a rare and complex condition associated with end-stage renal disease, characterized by painful, indurated and often exudative lesions (1,2). High mortality rate is associated with the presence of these wounds, often due to sepsis(2). Surgical debridement of these wounds is controversial especially in the presence of eschar (3-5). Maggot debridement therapy (MDT) has been used as an alternative to sharp debridement in complicated wounds, and has been shown to decrease postsurgical infection rates (6-8). There have been two previous case reports of patients with calciphylaxis in whom MDT was used (9,10). To our knowledge, this is the first case series examining MDT in patients with calciphylaxis ulcers. METHODS: Patients were selected and observed over a 2 year period from December 2003 to December 2005. All patients were dialysis dependent, two on hemodialysis (HD) and 2 on peritoneal dialysis (CAPD). Ages ranged from 23 to 63. All had secondary hyperparathyroidism and irregular, exudative, progressive wounds consistent with the diagnosis of calciphylaxis. Three had lower leg wounds and one had thigh wounds with a total of 9 wounds treated. Each patient had an average of 2 MDT treatments. Subsequent wound care included the use of silicone adhesive foam, negative pressure wound therapy (NPWT) and apligraf placement. One patient underwent parathyroidectomy. RESULTS: Pain medication requirements, need for amputation, wound progress and mortality were examined. Two patients, both on CAPD, had pain reduction with MDT and healed within the 2 year period. One patient required amputation. Three patients died including both patients who healed. Causes of mortality included sudden cardiac death, respiratory arrest and catastrophic CVA. None had sepsis related complications. Summary: Calciphylaxis is a marker of severe vascular disease. Once present, mortality is high, but maggot debridement therapy is a reasonable alternative to sharp debridement in order to promote healing, reduce infection and improve the quality of the patient's remaining life. Milas M, Bush RL, Lin P, Brown K, Mackay G, Lumsden A, Weber C, Dodson TF. Calciphylaxis and nonhealing wounds: the role of the vascular surgeon in a multidisciplinary treatment. J Vasc Surg. 2003;37(3):501Ð507 Roe SM, Graham LD, Brock WB, Barker DE. Am Surg. 1994;60(2):81Ð6.Calciphylaxis: early recognition and management Mureebe L, Moy M, Balfour E, Blume P, Gahtan V. Calciphylaxis: a poor prognostic indicator for limb salvage. J Vasc Surg. 2001;33(6):1275Ð1279 Howe SC, Murray JD, Reeves RT, Hemp JR, Carlisle JH..Calciphylaxis, a poorly understood clinical syndrome: three case reports and a review of the literature. Ann Vasc Surg. 2001;15(4):470Ð473 Martin, R. Mysterious calciphylaxis: wounds with eschar--to debride or not to debride? Ostomy Wound Manage. 2004;50(4):64Ð6, 68Ð70, discussion 71 Sherman RA. Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy. Diabetes Care. 2003;26(2):446Ð451..Armstrong DG, Salas P, Short B, Martin BR, Kimbriel HR, Nixon BP, Boulton AJ. Maggot therapy in "lower-extremity hospice" wound care: fewer amputations and more antibiotic-free days. J Am Podiatr Med Assoc. 2005;95(3):254Ð257 Sherman RA, Shimoda KJ. Presurgical maggot debridement of soft tissue wounds is associated with decreased rates of postoperative infection. Clin Infect Dis. 2004;39(7):1067Ð1070. Pliquett RU, Schwock J, Paschke R, Achenbach H. Calciphylaxis in chronic, non-dialysis-dependent renal disease. BMC Nephrol. 2003;29(4):8 Tittelbach J, Graefe T, Wollina U. Painful ulcers in calciphylaxis - combined treatment with maggot therapy and oral pentoxyfillin. J Dermatolog Treat. 2001;12(4):211Ð214.. |
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