Sudden onset postural livedo reticularis, cyanotic toes and multiorgan failure

Editor – I read with great interest the remarkable text of lesson of the month in ‘Sudden onset postural livedo reticularis, cyanotic toes and multiorgan failure’ (Clin Med June 2014 pp 314–5).

Although the case was typical of rare cholesterol embolisation syndrome (CES), the text in my opinion was lacking references to the following:

• workup of the hypercoaguable status of the catastrophic antiphospholipid syndrome¹ which can share clinical features of CES, in particular the acute development of livedo reticularis. Therefore, the relevant tests for such potential diagnosis, if any had been carried out, would have been worthwhile mentioning in the text

• hypereosinophilia, which is known to occur in up to 80% of CES²

• use of antiplatelet agents, and/or angiotensin-converting enzymes and angiotensin receptor blockers² in the management of the case. Use would seem reasonable as these agents tend to prevent other adverse cardiovascular events such as myocardial infarction, a leading cause of death in patients with atherosclerosis.^3,4

Despite all the above I still commend the authors who elegantly presented a rare but very serious condition.