Incorrect, this specimen does not show granuloma formation or significant cellular infiltration.

Correct! Calcification is a defining feature of this condition, involving the small arteries and arterioles.

Bacteria are not visualized in this biopsy specimen. Try again!

This stain is used to better visualize collagent structures, which appear black. Try again!

This stain is used to identify areas of fibrosis. Pick again!

Correct! The von Kossa stain can used to identify calcium phosphate deposits. The silver ions in the stain react with phosphate. Photochemical degradation of silver phosphate to silver then occurs under light illumination

C4d deposition may occur in the setting of classical complement pathway activation (i.e. antibody mediated rejection of a transplant). This is unlikely here, try again!

This would not be the best initial step. Debridement is often avoided altogether, as manipulation can increase the risk of ulceration, new or worsening necrosis, or super-infection. Try something else first!

It will be crucial to bring down this patient’s phosphate level and closely manage her hyperparathyroidism. Non-calcium containing phosphate binders should be used, and compliance should be encouraged.

Absolutely! Expert wound care will be crucial in this condition.

Correct! Warfarin is a risk factor for this condition and is implicated in its pathogenesis due to its inhibition of vitamin-K dependent pathways. This patient should be off warfarin, and an alternative should be discussed with the multidisciplinary team.

While this condition has very high risk of super-infection, these lesions do not appear to be actively infected at this time.

There is no indication for steroids (systemic, topical, or intra-lesional) in this condition, and local trauma should be avoided.

Vitamin D supplementation can lead to increased calcium absorption from the GI tract, leading to higher serum calcium levels which can worsen this condition.

Sodium thiosulfate has actually been shown to cause an elevated anion-gap metabolic acidosis, which can in some cases be severe.

Nausea and vomiting are common side effects of sodium thiosulfate therapy.

Sodium thiosulfate can cause hypotension, and blood pressure should be monitored closely.

Sodium thiosulfate has not been shown to cause suppression of the immune system.

While sodium thiosulfate can cause headache or confusion/disorientation, seizure is not one of the known adverse effects.