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.