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Cutaneous cholesterol embolization
Gulden Avci1, Tayfun Akoz, Aylin Ege Gul
1Department of Plastic and Reconstructive Surgery, Canakkale Onsekiz Mart University, Canakkale, Turkey.
Insights
Cholesterol embolization syndrome, a rare condition, arises from cholesterol plaque rupture, often after medical procedures. Diagnosis requires clinical and histologic evaluation for effective management.
Area of Science:
- Dermatology
- Vascular Medicine
- Pathology
Background:
- Cutaneous cholesterol embolization syndrome (CCES) results from cholesterol emboli dislodged from atherosclerotic plaques.
- CCES is often iatrogenic, linked to vascular procedures, anticoagulation, or thrombolytic therapy.
- Kidneys, gastrointestinal tract, and skin are the most frequently affected organs.
Observation:
- Two cases of CCES are presented: a 74-year-old with acute chest pain and a 69-year-old with hyperglycemia, hyperlipidemia, and hypertension.
- Patients developed livedo reticularis, skin necrosis, and, in one case, impaired renal function and cyanotic toes.
- Skin biopsies confirmed cholesterol clefts in small arteries and arterioles.
Findings:
- Histologic examination of skin biopsies revealed characteristic cholesterol clefts within small arteries and arterioles.
- Clinical presentation included livedo reticularis, progressing to necrotic skin lesions in the lumbar region, hips, and lower extremities.
- Both patients required debridement of necrotic tissue and secondary wound healing.
Implications:
- Accurate diagnosis of CCES hinges on integrating clinical presentation with histopathological findings.
- A multidisciplinary approach is crucial for managing CCES, particularly when multiple organ systems are involved.
- Prompt diagnosis and management are essential to prevent further embolic events and complications.
Background:
Cutaneous cholesterol embolization syndrome occurs as a result of cholesterol embolization from atherosclerotic plaques lining the walls of arteries and arterioles. It can occur sporadically but is more commonly associated with iatrogenic manipulation via invasive vascular procedures or therapies (anticoagulation or thrombolytics) The three most common organ systems afflicted by cholesterol emboli include the kidneys, gastrointestinal system, and skin.
Main Observations:
We present two patients with cutaneous cholesterol embolization A 74-year-old with no prior disease or trauma was referred to the hospital with the acute chest pain. After 24-48 he developed livedo reticularis, followed by necrotic areas like bilaterally on hips and in the lumbar region. The second patient, 69-year-old man with a history of hyperglycemia, hyperlipidaemia, and hypertension was referred with weight loss, bilateral livedo reticularis, severe pain of lower extremities and impaired renal function. The toes first became cyanotic and than skin necrosis developed. Skin biopsy revealed presence of cholesterol clefts in the lumina of small arteries and arterioles. In both patients the necrotic skin and subcutaneous tissue had been debrided. Daily dressing was applied and tissue defects underwent secondary healing.
Conclusion:
The diagnosis of cholesterol embolization relies on clinical and histologic examination. Both, diagnosis and treatment needs a multidisciplinary approach, especially in cases of multi-organ involvement.
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