Livedo reticularis due to multiple cholesterol emboli

A case of skin necrosis as a result of cholesterol crystal embolisation

Cholesterol crystal embolism is a multisystem disorder with a high mortality. It is usually seen following vascular surgery and long term anticoagulation therapy, but the diagnosis is often not considered. Skin manifestations are the first sign of cholesterol crystal embolism and recognition of the symptoms is a key element in early diagnosis and prevention of recurrences. We report a case who presented with acute renal failure, livedo reticularis and skin necrosis following angioplasty. Cutaneous biopsy revealed cholesterol crystals in the lumen of a vessel. Necrotic sites were treated with daily wound care and he was operated for reconstruction of tissue defects with cutaneous advancement flaps. One month after the operation healing was complete.

Cutis marmorata resemblance after liposuction

Liposuction is a safe method for the treatment of lipodystrophy. It gives good results in relation to body contours, especially when the superficial and deep layers of the superficial fascia are aspirated. The authors present clinical cases of female patients who underwent liposuction of the abdomen, flanks, and back in which superficial and deep liposuction was used. In the immediate postoperative period, these patients presented a skin pattern of marbled appearance, involving rosy-purplish stains intermingled with other whitish stains on the skin in the areas subjected to surgery and resembling the cutis marmorata described in the literature. Even 1 year after the operation, the stains had not receded. The literature mentions cases of cutaneous necrosis provoked by a temperature increase induced by liposuction cannulas. This trauma said to be the determining factor for local lesions of the subdermal plexus. However, no cases involving lesions of this plexus attributable to mechanical trauma from cannulas are cited. According to several authors, it is important during superficial liposuction to maintain a strip about 1 cm thick under the deep dermis for the preservation of the arterial plexus of the skin. This would avoid the formation of a skin pattern resembling cutis marmorata.

Enfermedad por émbolos de cristales de colesterol

Cholesterol crystal embolism (CCE) is an infrequent entity that primarily appears in males over the age of 60 with generalized arteriosclerosis after angiographic procedures, vascular surgery or, more rarely, with oral anticoagulant treatment with heparin or with fibrinolytics. We present the case of a patient with several risk factors for CCE, who presented with the pathognomonic triad of leg and foot pain, livedo reticularis and palpable pedal pulses. The diagnosis was based on the fact that cholesterol crystals were seen in the arterioles in the skin biopsy. Due to the frequency with which the skin manifestations appear and the importance of early diagnosis and treatment, an awareness of these crystals is fundamental in diagnosing these processes.

Isolated splenic infarction following left cardiac catheterization: case report and a review of the literature

A cardiac catheterization was performed in a 57-year-old man for post-infarction angina. A severe left flank pain developed following the angiography. Ultrasonography, computed tomography, and radionuclear scanning of the abdomen showed splenic infarction. An isolated cholesterol atheroembolism of spleen from disrupted atheromatous plaques so far has not been reported.

Livedo reticularis and massive thoracoabdominal aneurysm

Cholesterol crystal embolization arising from an atheromatous aortic aneurysm is a potentially treatable condition. We report a 55-year old man with a sudden onset of painful livedo reticularis of the buttocks and lower limbs secondary to a massive thoracoabdominal aortic aneurysm, discovered incidentally when the patient underwent a liver ultrasound test. The diagnosis of cholesterol crystal embolization of the skin requires a high degree of clinical suspicion. Abdominal ultrasound should be considered in the routine assessment of lower limb livedo reticularis.

Inflammatory ulcers

A large number of diseases can eventuate in cutaneous ulceration. This article will review inflammatory disorders which by their nature can directly produce cutaneous breakdown and ulcer formation. Major emphasis is given to those disorders where recent knowledge has improved our understanding of the condition or where new therapeutic agents or maneuvers have become available. This later group consists of vasculitis, disorders caused by small vessel thrombi or embolus and pyoderma gangrenosum.

Cholesterol embolism to the skin

The clinical features of a patient with cholesterol embolism are presented. Histopathological examination showed the typical clefts of cholesterol in the skin and renal vessels. We believe this entity is under-reported in the dermatological literature.

[Incidence of cholesterol embolisms in 70 atheromatous patients hospitalized for cardiovascular evaluation]

Cholesterol crystal embolization must be considered in all atheromatous patients hospitalized for cardiovascular evaluation. Because this is a difficult and often belated diagnosis, between June 1989 and June 1990 a prospective study was conducted on 70 patients. Clinical monitoring, including examination of the fundus oculi, was performed before, and on the 5th day of cardiovascular investigations. The incidence of systemic emboli (12.8%) detected in this way corresponds to that reported in rare published series. Funduscopy is a simple, rapid and little expensive examination which should improve the investigative procedures and point to the best treatment.

Cholesterol atheroembolism: an increasingly frequent complication of cardiac catheterisation

Cholesterol atheroembolisation is increasingly encountered as a complication of cardiac catheterisation. We report three cases seen recently in our unit. Autopsy and histological evidence confirmed cholesterol atheroembolism in one case, while the other two patients presented with classical clinical features of this condition. All three patients were elderly with extensive atheromatous disease. No excessive difficulty was encountered at catheterisation. Embolisation involved the gastrointestinal tract, the skin and extremities, and the kidneys. Despite anticoagulation, dialysis and surgical intervention all our patients died. With investigative and therapeutic catheterisation being increasingly performed in the setting of severe atherosclerosis, the need for continued scrutiny for catheter-induced complications is emphasised.

Management of multiple cholesterol embolization syndrome--a case report

A sixty-two-year-old man who underwent coronary angiography and received acute thrombolytic and anticoagulant therapy for acute myocardial infarction developed multisystemic injury, including renal insufficiency and cutaneous manifestations. Fundoscopic examination and skin biopsy specimen led to the diagnosis of multiple cholesterol embolization syndrome (MCES). Discontinuation of anticoagulants and administration of hemostatic (carbazochrome, tranexamic acid, reptilase, and vitamin K) and antihyperlipidemic (cholestyramine and probucol) drugs resulted in temporary improvement of cutaneous and renal disorders and extended survival for about one year. Besides severe aortic atherosclerosis, postmortem examination revealed numerous cholesterol emboli to multiple organs. MCES is a rare but serious complication of left heart catheterization and anticoagulant therapy, and the optimal treatment remains to be established. The authors suggest here that the above-mentioned therapy might be effective for management of MCES.

Cholesterol crystal embolization: a review of 221 cases in the English literature

Cholesterol crystal embolization (CCE) frequently presents with nonspecific manifestations that mimic other systemic diseases. The authors reviewed 221 cases of histologically proven CCE in the English literature to define the clinical, laboratory, and pathologic characteristics of this disorder. CCE affected predominantly elderly males (mean age sixty-six) with a frequent history of hypertension (61%), atherosclerotic cardiovascular disease (44%), renal failure (34%), and aortic aneurysms (25%) at presentation. At least one possible predisposing factor was present in 31% and included operative and radiological vascular procedures and the use of anticoagulants. Cutaneous findings (34%) and renal failure (50%) were two of the most common clinical findings throughout the course of CCE. The nonspecific signs and symptoms included: fever (7%), weight loss (7%), myalgias (4%), and headache (3%). Premortem diagnoses were established in 31% of patients most commonly by biopsy of the muscle, skin, and kidney. Mortality was high (81%) and was most commonly due to multifactorial, cardiac, and renal etiologies. The authors conclude that CCE should be strongly considered in elderly patients with atherosclerotic vascular disease who have the onset of renal insufficiency and cutaneous manifestations. CCE may be confirmed by a skin or muscle biopsy.

Cutaneous cholesterol emboli with infarction clinically mimicking heparin necrosis--a case report

Cutaneous necrosis secondary to anticoagulation (heparin and warfarin) and cholesterol (atheromatous) emboli can be similar clinically and histologically. A unique case is reported of cholesterol emboli clinically mimicking heparin necrosis. The patient was a 57 year old white male who underwent coronary angioplasty and was treated with intravenous heparin. Shortly after he developed large ecchymotic areas at the level of the umbilicus and distally which progressed to eschar. Renal failure ensued and he died secondary to stress ulcers. Cholesterol emboli were demonstrated in small muscular arteries of the dermis and panniculus along with a full thickness infarct. Because of the increasing popularity of angioplasty utilizing a retrograde femoral approach plus heparin anticoagulation, it is important to recognize the difficulty in making a clinical diagnosis when cutaneous necrosis supervenes. An incisional biopsy of the skin is recommended.