Alaminos, Miguel

Aneiros-Fernández, José

Arias-Santiago, Salvador

Buendía-Eisman, Aguistin

Carriel Araya, Víctor Sebastián

González-Andrades, Miguel

Orgaz-Molina, Jacinto

Cleveland Clinic Journal of Medicine

English

Ghent University Academic Bibliography

Salvador ariaS-Santiago, Md, PhdDepartment of Dermatology, San Cecilio University Hospital, Department of Dermatology, Baza General Hospital, and Department of Histology, School of Medicine, Granada University, Granada, SpainThe Clinical PictureA skin lesion after cardiac catheterizationA 64-year-old man with diabetes and hy-pertension presented with a 2-day history of sudden onset of acute pain and cyanosis on the sole of his right foot 4 days after undergo-ing cardiac catheterization and coronary an-giography. The physical examination revealed macu-lar, violaceous, connecting rings in a net-like pattern that blanched with pressure and dis-appeared when the foot was elevated, a pre-sentation compatible with livedo reticularis (Figure 1). Laboratory testing (complete blood cell count, biochemistry panel, coagulation test, and C-reactive protein test) was notable only for eosinophilia.  A few days later, the patient returned with abdominal pain, diarrhea, and acute renal in-jury with urinary eosinophils (7% of the white blood cells in the urine) and proteinuria. Q: Which is the most likely diagnosis? □ Infective endocarditis □ Pernio (chilblain) □ Cholesterol crystal embolism □ Cutaneous small-vessel vasculitisA: Cholesterol crystal embolism is the correct diagnosis. Infective endocarditis is an infection of the endocardium, but systemic signs may be present, including cutaneous lesions such as Osler nodes (painful papules on the tips of the fingers and toes) and Janeway lesions (painless macules on the palms and soles). Histologic staining of skin biopsy specimens often shows vasculitis, occasionally with a positive Gram stain. Severe renal injury is not common, and the timing of the acute illness and skin lesion fits better with an acute embolic phenomenon.  Pernio is a form of cold injury, localized in peripheral parts of the body and occurring after exposure to cold temperatures in damp condi-tions. It usually manifests bilaterally as pain-ful erythematous or purple lesions on the acral areas of the hands and feet, nose, ears, and, rarely, the thighs and buttocks. Pernio most commonly affects women between 20 and 40 years of age. It can be idiopathic or associated with a systemic disease such as systemic lupus erythematosus or Sjögren syndrome.  Cutaneous small-vessel vasculitis is a het-erogeneous group of disorders with inflamma-tion and damage of the blood vessels; it may be limited to the skin or it may involve multiple systems. Palpable or nonpalpable purpura and ulceration are common clinical findings, and histologic study shows an inflammatory infil-trate of vessel walls, fibrinoid necrosis, throm-bosis, and extravasation of red blood cells. The CliniCal PiCTuredoi:10.3949/ccjm.79a.10108JoSe aneiroS-Fernández, MdDepartment of Pathology, San Cecilio University Hospital, Granada, Spainvictor carriel, PhdDepartment of Histology, School of Medicine, Granada University, Granada, SpainJacinto orgaz-Molina, MdDepartment of Dermatology, San Cecilio University Hospital, Granada, SpainMiguel gonzález-andradeS, Md, PhdDepartment of Histology, School of Medicine, Granada University, Granada, SpainaguStín Buendía-eiSMan, Md, PhdDepartment of Dermatology, School of Medicine, Granada University, Granada, SpainMiguel alaMinoS, Md, PhdDepartment of Histology, School of Medicine, Granada University, Granada, SpainFigure 1. Macular violaceous connecting rings in a net-like pattern compatible with livedo reticularis on the foot.424 CLEVELAND CLINIC JOURNAL OF MEDICINE  VOLUME 79  • NUMBER 6  JUNE 2012CLEVELAND CLINIC JOURNAL OF MEDICINE  VOLUME 79  • NUMBER 6  JUNE 2012 425arias-sanTiago and Colleagues While this patient’s problems are not con-sistent with small-vessel vasculitis, the single skin lesion, the timing after the catheteriza-tion, and the urinary eosinophils are best ex-plained by cholesterol embolization. ■ Cholesterol Crystal embolismCholesterol crystal embolism is commonly iatro-genic, a complication of mechanical damage to the arterial walls from vascular surgery or invasive percutaneous procedures. Material dislodged from atheromatous arterial plaques can occlude the small vessels of the feet, pro-ducing this syndrome. The onset of the clinical disease is often delayed for days to weeks after an angio-graphic procedure.1 Spontaneous hemorrhage, disruption of plaque, or drug therapy with an anticoagulant or a fibrinolytic can precipi-tate embolization of cholesterol crystals. The source of the emboli is atheromatous plaque in major blood vessels, particularly the abdomi-nal aorta.many organs and systems can be affectedThese emboli can affect many organs and sys-tems: eg, the kidneys (causing hypertension and acute renal failure), the muscles (causing myalgias), gastrointestinal organs (causing bleeding, abdominal pain, and bowel infarc-tion), the lungs (causing acute respiratory distress syndrome), the eyes (causing Hollen-horst plaques in retinal arteries), and the cen-tral nervous system (causing stroke, confusion, and delirium). Cardiac or central nervous sys-tem involvement is associated with a high risk of death.  After angiography, clinical manifestations of cholesterol embolization have been report-ed in 0.06% to 1.4% of patients,2,3 although the finding of cholesterol emboli is more com-mon in autopsy studies.4 recognizing skin signs is the keyCutaneous abnormalities are usually the ear-liest and often the only clinical manifesta-tion of this syndrome. Findings on the lower limbs include blue toes, cutaneous nodules, and livedo reticularis, affecting the feet and legs and sometimes extending upward to the trunk. Other findings include digital infarcts, ulceration, gangrene, purpura, cyanosis, and splinter hemorrhages in the nail bed. In our patient, microscopic study of skin biopsy specimens showed needle-shaped clefts within the lumen of blood vessels—ie, dis-solved cholesterol crystals obstructing small arteries (Figure 2). Biopsy studies of skin lesions are posi-tive in a high percentage of cases, showing dissolved cholesterol crystals within the lu-men of blood vessels, especially in the small to large arteries and arterioles of the deep dermis or subcutaneous fat. Deep biopsies and carefully examination are necessary, as emboli tend to be patchily distributed. Early recognition of cutaneous clinical findings is essential to establish the proper diagnosis and treatment. The diagnostic triad of this disease in-cludes blue toe syndrome, acute or subacute renal failure, and a temporal relation with an inciting event (particularly angiography). But despite these diagnostic criteria,2 the diagnosis is often based on a combination of signs and symptoms specific to end-organ damage and a systemic inflammatory response.3  Histologic confirmation is considered es-sential to the diagnosis of cholesterol crystal embolism, and as the skin is the most acces-sible site, skin biopsy provides the best sample for histologic diagnosis.5  Postprocedural embolism of a blood clot, vasculitis, and infective endocarditis are the most important differential diagnoses.6,7Figure 2. Skin biopsy showed needle-shaped clefts within the lumen of blood vessels, ie, dissolved cho-lesterol crystals obstructing small arteries.The diagnostic triad: blue toe syndrome, acute or  subacute renal failure, and a recent inciting event such as angiography426 CLEVELAND CLINIC JOURNAL OF MEDICINE  VOLUME 79  • NUMBER 6  JUNE 2012treatment is supportive, preventiveTreatment is mainly supportive with hemo-dynamic monitoring, nutritional and meta-bolic support, mechanical ventilation, and dialysis if necessary. The underlying athero-sclerotic disease should be treated aggressive-ly. Prevention of another episode involves modification of traditional risk factors such as serum cholesterol, diabetes, hypertension, and smoking. Additional vascular surgery procedures should be avoided, as they can in-duce new episodes. ■ ■ referenCes 1. Donohue Kg, Saap L, Falanga V. Cholesterol crystal em-bolization: an atherosclerotic disease with frequent and varied cutaneous manifestations. J Eur Acad Dermatol Venereol 2003; 17:504–511. 2. Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A; Cholesterol embolism Study (CHeST) inves-tigators. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac cath-eterization: a prospective study. J Am Coll Cardiol 2003; 42:211–216. 3. Johnson LW, esente P, giambartolomei A, et al. Periph-eral vascular complications of coronary angioplasty by the femoral and brachial techniques. Cathet Cardiovasc Diagn 1994; 31:165–172. 4. Kronzon i, Saric M. Cholesterol embolization syndrome. Circulation 2010; 122:631–641. 5. Jucgla A, Moreso F, Muniesa C, Moreno A, Vidaller A. Cholesterol embolism: still an unrecognized entity with a high mortality rate. J Am Acad Dermatol 2006; 55:786–793. 6. Maki T, izumi C, Miyake M, et al. Cholesterol embolism after cardiac catheterization mimicking infective endo-carditis. Intern Med 2005; 44:1060–1063. 7. Arias-Santiago S, Aneiros-Fernández J, girón-Prieto MS, Fernández-Pugnaire MA, Naranjo-Sintes r. Palpable purpura. Cleve Clin J Med 2010; 77:205–206.ADDRESS: Salvador Arias-Santiago, MD, Department of Dermatology, San Cecilio University Hospital, Av Dr. Oloriz 16, Granada 18012, Spain; e-mail salvadorarias@hotmail.es.skin lesion afTer CardiaC CaTheTeriZaTionvisit our web site at http://www.ccjm.orgcontact us by e-mail at ccjm@ccf.org

A skin lesion after cardiac catheterization

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A skin lesion after cardiac catheterization

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