Introduction: Calciphylaxis, or calcific uremic arteriolopathy, is a rare and serious disorder that presents with excruciatingly painful skin ischemia and necrosis. Most commonly, this disorder occurs in the setting of end stage renal disease.

Case Presentation: Patient is a 53 year old male with a history of end stage renal disease (on hemodialysis), coronary artery disease, hypertension, type II diabetes, heart failure with reduced ejection fracture (40%), and HIV who was admitted to the ICU due to diabetic ketoacidosis and found to have a necrotic penis and scrotum. Physical exam revealed a desquamated left hemisphere of the scrotum with exposed subcutaneous fat. Lower extremities reveal bilateral inguinal lymphadenopathy. Differential Diagnosis included Fournier's Gangrene and cellulitis. CT scan of the pelvis revealed siginificant calcification of the internal pudendal arteries.

Working Diagnosis: Penile Calciphylaxis (Calcific Uremic Arteriolopathy)

Management: Partial penectomy with wide excision of necrotic scrotal tissue. Multiple debridement procedures and dressing changes, along with a penile tissue biopsy, until discharge to skilled nursing facility on hospital day 44. Patient is to continue hemodialysis, follow up with general surgeon outpatient, and continue wound care with Calcium Alginate.