Cholesterol embolism and acute interstitial nephritis: two adverse effects of streptokinase thrombolytic therapy in the same patient

Cholesterol embolization syndrome induced by thrombolytic therapy

Cholesterol embolization syndrome (CES) induced by thrombolytic therapy is a rare syndrome with a high incidence of morbidity and mortality. The variability in clinical presentations may cause a delay in diagnosis of CES. This article presents a comprehensive review of the English literature from January 1980 to December 2007 identifying all published case reports of CES induced by thrombolytic therapy. Multiple electronic databases were searched and relevant reference lists were hand searched to identify all case reports. Thirty cases of thrombolytic-induced CES were identified. Indications for thrombolysis were acute myocardial infarction (28 patients) and deep venous thrombosis (two patients). Skin and renal involvement were the most common presentations. Skin manifestations included livedo reticularis, rash, and skin mottling. Other clinical symptoms included cyanotic toes, gastrointestinal bleeding, or perforation, myalgias, retinal emboli, and CNS involvement. Morbidity and mortality were high. Outcomes included chronic hemodialysis in eight patients, four patients underwent amputations, seven patients developed or had progression of their chronic kidney disease, and seven deaths occurred.CES presents as multiorgan dysfunction and should be considered in the differential diagnosis of the symptom complex that may develop after thrombolytic therapy. Diagnosis of CES can be difficult as a result of the variable clinical presentations. A thorough clinical history and physical examination are essential first steps in establishing a diagnosis. Confirmatory diagnosis requires biopsy of the target organs. Measures to reduce the likelihood of recurrence should be taken and include avoidance of anticoagulation therapy and vascular procedures. Unfortunately, therapy remains supportive and the outcome is invariably poor.

Adverse dermatologic effects of cardiovascular drug therapy: part III

Cardiovascular disease is common, affecting an increasing number of persons as the population ages. To combat this growing health problem, physicians use a multitude of medications in the treatment of their patients. Although pharmacologic therapy greatly enhances quality of life for a majority of patients, there is always the potential for an unfavorable reaction. For example, cardiovascular drugs can induce a vast array of adverse dermatologic responses. This article reviews the various cutaneous reaction patterns that can occur as a result of treatment with vasodilators and other antihypertensive drugs, anticoagulants and antiplatelet drugs, thrombolytic agents, and lipid-lowering agents.