Case Studies

A Snowflake-Like, Powdery Substance

on the Head and Neck of an Adult Male

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Lijo John, MD,1 Tapan Patel, MD,1 Steven Hays, MD, FACP,1 Andrew Fenves, MD, FACP,1
Frank Wians Jr., PhD, MT(ASCP)2
(Departments of 1Medicine and 2Pathology, Baylor University Medical Center, Dallas, TX)
DOI: 10.1309/LMQFF2V1OO0WABTM

Clinical History
Patient: 53-year-old African-American male
Chief Complaint: Shortness of breath, lower
extremity swelling, nausea, vomiting, diarrhea,
altered taste sensation, and decreased urine
output.
History of Present Illness: Patient presented
to the emergency room (ER) with complaints of
nausea and vomiting for 2 months, shortness
of breath for the last few days, altered taste
sensation, and worsening of preexisting
lower extremity swelling. Other complaints
included blurred vision, diarrhea, and extreme
weakness.
Past Medical and Surgical History: Type II
diabetes mellitus and hypertension for about
10 years. No significant surgical history.
Social History: No tobacco use, occasional
alcohol use, and no IV drug abuse.
Physical Exam Vital Signs: Temperature,
97.7°F; respiratory rate, 20/minute and
unlabored; pulse, 91 bpm; and, blood pressure,
177/80 mmHg. Pertinent physical examination
findings were significant for lower extremity
edema up to the knees, and the presence of
fine white crystals distributed in patches on the
head and neck (Image 1).
Principal Laboratory Findings: Table 1.
Keywords: blood urea nitrogen, uremia,
uremic frost

Questions Possible Answers

1. What are this patient’s most striking clinical and laboratory 1. The presence of a very fine, snowflake-like, powdery
finding(s)? substance on the patient’s head and neck (Image 1) and mark-
2. How do you explain this patient’s most striking laboratory edly elevated blood urea nitrogen (BUN) and serum creati-
findings? nine levels and a markedly decreased estimated glomerular
3. What is this patient’s skin condition called and what filtration rate (eGFR) and carbon dioxide level (Table 1).
causes it?
4. What is the clinical significance of this patient’s clinical 2. This patient’s markedly abnormal laboratory findings
and laboratory findings? (BUN, creatinine, eGFR, CO2) are clearly due to endstage
5. How should this patient be treated? renal disease (BUN, creatinine, eGFR), uncontrolled diabetes
(CO2), and diarrhea (CO2). Our patient’s eGFR is consistent
with Stage V chronic kidney disease (CKD) (Table 2).

3. Uremic frost caused by the accumulation of urea and

other nitrogenous waste products in sweat that crystallize with
evaporation.2 This is a rare but well recognized manifestation
Corresponding Author
of untreated uremia in patients with advanced CKD. It oc-
Tapan Patel, MD curs often, but not always, in patients with a BUN level in
tapan.patel@baylorhealth.edu excess of 200 mg/dL.3 Our case is unusual because the BUN
was only 130 mg/dL. Moreover, we have observed that some
patients with severe uremia and very high BUN levels (>200
mg/dL) do not develop uremic frost. It is not clear why some
Abbreviations uremic patients demonstrate this unusual dermatological en-
ER, emergency room; BUN, blood urea nitrogen; eGFR, estimated
tity while others do not.
glomerular filtration rate; CKD, chronic kidney disease
4. Uremic frost is a visually fascinating condition that can
be mistaken for a variety of dermatological disorders (eg,

196 LABMEDICINE ■ Volume 42 Number 4 ■ April 2011 labmedicine.com

 Case Studies

A            B

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Image 1_White, snowflake-like patches of powdery crystals on the patient’s (A) head, (B) neck, and chin areas.

seborrhoeic dermatitis, fungal infection, etc). After scrap-
ing crystals from our patient’s skin and dissolving them in
physiological saline, we assayed this sample and an equiva-
lent volume of saline blank for BUN. The BUN levels in the
saline sample containing the skin scrapings and the saline
blank were 24 mg/dL and undetectable, respectively. It has
been estimated that an average resting male with a BUN of
18 mg/dL has a sweat urea concentration of approximately
67 mg/dL.4
1. CKD Stages. Available at www.renal.org/whatwedo/InformationResources/
CKDeGUIDE/CKDstages.aspx. Accessed November 16, 2010.
2. Walsh SR, Parada NA. Images in clinical medicine. Uremic frost. N Engl J
Med. 2005;352:e13.
3. Pol-Rodriguez MM, Wanner M, Bhat P, et al. Uremic frost in a critically ill
patient. Kidney Int. 2008;73:790.
4. Mickelsen O, Keys A. The composition of sweat, with special reference to
the vitamins. J Biol Chem. 1943;149:479-490.

5. The treatment of this condition is renal replacement

therapy such as hemodialysis or peritoneal dialysis. Uremic
frost disappeared from our patient’s skin after initiation of
hemodialysis. LM

Table 1_Principal Laboratory Findings Table 2_eGFR Values Associated With Various Stages
of CKD1
Test Patient’s Result Reference Interval
Hematology CKD
Stage eGFR, mL/min/1.73 m2 Interpretation
WBC count 11.5 4.5-11.0 × 109/L
RBC count 2.83 3.80-5.40 × 1012/L 1 ≥90 with CKD risk factorsa Increased risk for CKD
Hemoglobin 7.9 12.0-16.0 g/dL ≥90 Normal kidney function but urine findings
Hematocrit 23.7 37-47%    or structural abnormalities may
Platelet count 299 150-450 × 109/L    suggest kidney disease
Chemistry 2 60-89 Mildly reduced kidney function, which
Sodium 138 136-145 mEq/L    may suggest kidney disease
Potassium 4.9 3.6-5.0 mEq/L
Chloride 112 98-107 mEq/L 3 30-59 Moderately reduced kidney function
CO2 5 22-30 mEq/L 4 15-29 Severely reduced kidney function
Albumin 3.2 3.2-5.5 g/dL 5 <15 (or patient on dialysis) Very severe or endstage kidney failureb
BUN 132 6-20 mg/dL aRisk factors include, but are not limited to: family history of CKD, hypertension, diabetes,
Creatinine 21.8 0.5-1.2 mg/dL
autoimmune diseases, systemic infections, urinary tract infections, urinary stones, neopla-
eGFR 3 >60 mL/min/1.73 m2 sia, and exposure to certain drugs.
bAlso known as “established renal failure.”
BUN, blood urea nitrogen; eGFR, estimated glomerular filtration rate (MDRD equation);
MDRD, modification of diet in renal disease. CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate.

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