[Cholesterol embolism: a diagnostic puzzle and a therapeutic dilemma]

A well documented and histologically proven case of cholesterol embolism is discussed, and the recent literature is reviewed. This disorder is usually underdiagnosed and commonly detected only at autopsy. Elderly people with atherosclerotic vascular disease are predominantly affected. Cholesterol embolization can occur spontaneously, but it often results from medical interventions such as arterial invasive procedures, vascular surgery, anticoagulation or thrombolytic therapy. Clinical manifestations are manifold, and two distinct patterns are generally observed: a mild peripheral cutaneous form and a severe visceral form that frequently mimics other systemic diseases. Transient eosinophilia is an important laboratory finding, and it is present in about 80% of the cases. Cholesterol crystals are rarely found in retinal arteries, and premortem diagnosis is established most commonly by biopsy of the muscle, skin or kidney. The role of various therapeutic modalities is still controversial and does not seem to change the course of this frequently fatal disease. The treatment is symptomatic, and the surgical correction of the embolic source is recommended only in the case of peripherally embolizing stenotic lesions. The most effective measures are prevention and the identification of patients at risk. In these patients the aforementioned precipitating events should be avoided, or the potential risk must be carefully weighed against the possible benefits in this particularly fragile group of patients.