A 50-year-old man with end-stage kidney disease receiving hemodialysis was admitted to the hospital for treatment of calciphylaxis and foot cellulitis. His home medications included sevelamer and hydrocodone-acetaminophen (10 mg/325 mg) every 8 hours as needed, which was increased to every 4 hours as needed in the hospital. Hydromorphone (0.5 mg intravenously as needed) was added for breakthrough pain. He was prescribed chewable lanthanum tablets (500 mg 3 times daily) for treatment of a blood phosphate level of 8.1 mg/dL (reference, 2.5-4.5 mg/dL).
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On hospital day 7, the patient developed intermittent apneic episodes, during which his oxygen saturation was 80% on room air; heart rate, 86/min; and blood pressure, 106/45 mm Hg. Physical examination revealed bilateral rhonchi and responsiveness to verbal commands only with deep painful stimulus. A chest radiograph showed 4 radio-opaque coin-shaped opacities in the stomach (Figure). After administration of oxygen at 2 L/min by nasal cannula and a naloxone infusion, his oxygen saturation increased to 98% and his mental status improved. The patient reported no foreign body ingestion.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Neil Shadbeh Evans, MD, Department of Medicine, UC Davis Medical Center, 4301 X St, Sacramento, CA 95817 (firstname.lastname@example.org).
Published Online: October 30, 2023. doi:10.1001/jama.2023.19032
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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