[Cholesterol crystal embolisms due to systemic thrombolysis of an acute myocardial infarct]

A 63-year-old male patient admitted with acute inferior myocardial infarction was treated with tissue plasminogen activator (rt-PA) and heparin. 4 hours after the initiation of the rt-PA infusion he showed painful cutaneous alterations on the lower trunk, mistaken as drug-induced rash and later correctly identified as livedo reticularis. Simultaneously, renal function deteriorated. Assuming hypersensitivity vasculitis, we instituted immunosuppressive treatment which proved to be ineffective. Skin biopsy including the deeper layers showed multiple cholesterol emboli. Anticoagulants were stopped and we noticed no further cholesterol embolism or further decline of renal function. 10 previous publications have mentioned a causal relationship between systemic fibrinolytic treatment and the cholesterol crystal embolism syndrome. In 7 cases, however, angiographic procedures were used or the interval between fibrinolysis and the occurrence of cholesterol crystal embolism was too long to exclude spontaneous or heparin-induced cholesterol crystal embolism. The short interval in our own case points clearly to the systemic fibrinolytic therapy as the culprit. We would like to draw attention to the possibility that in individuals with advanced atherosclerotic lesions of the aorta or major arteries, systemic fibrinolytic treatment of myocardial infarction may give rise to the cholesterol crystal embolism syndrome.