In March 2008, the patient was readmitted for a painful necrotic ulcer on his right calf. He had no other complaints except for mild dyspnea on exertion. His medications included nifedipine ER (90 mg daily), metoprolol (100 mg bid), multivitamins (one capsule daily), calcium acetate (2,001 mg tid), and warfarin (5 mg daily). Vital signs were normal with an arterial oxygen saturation of 94% on room air. His physical examination was remarkable for a 3/6 aortic systolic ejection murmur, few scattered crackles on both lungs, and trace bilateral lower extremities edema. Chest radiograph on admission revealed diffuse bilateral infiltrates (Fig 1B). Significant laboratory study values were as follows: international normalized ratio, 2.3; creatinine, 6.4 mg/dL; blood urea nitrogen, 48 mg/dL; calcium, 8.4 mg/dL (corrected); phosphorus, 6.0 mg/dL; alkaline phosphatase, 534 IU/L (normal range: 34-124); and albumin, 3.0 g/dL.