Report
Cholesterol embolism: Still an unrecognized entity with a high mortality rate

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Background

Cholesterol embolism (CE) is an increasingly common but often underdiagnosed medical problem. The recognition of clinical manifestations of CE is the first step toward a correct diagnosis.

Objective

Our aim was to characterize the features of CE and the risk factors for fatal outcome.

Methods

Clinical records of patients with clinical and histopathologic diagnoses of CE seen from January 1993 through March 2003 were reviewed.

Results

Twenty-six male patients were identified. Mean age was 64 years (range, 48-88 years). All patients had two or more risk factors for atherosclerosis. All but one patient had preexisting symptomatic atherosclerotic disease. At least one precipitating factor was identified in 23 patients (88%). Diagnosis of CE at admission was made in 9 patients only (35%). Cutaneous lesions (88%) and renal failure (73%) were the most common clinical findings. Complications (dialysis, acute pulmonary edema, amputation, or gastrointestinal surgery) were present in 21 patients (81%), and 15 patients died (58%). Previous chronic renal failure was the only variable associated with mortality (relative risk: 4.54, 95% confidence interval 1.26-16.6; P = .02).

Limitations

The results were obtained from patients admitted to a university hospital. This fact may have selected a higher proportion of severe cases.

Conclusions

CE was frequently misdiagnosed. Skin lesions were the most common clinical findings and skin biopsy provided histologic confirmation in most of the patients. Chronic renal failure was the only factor related to death.

Section snippets

Data collection

We collected and reviewed all clinical, laboratory, and histologic data of all cases of histologically proven CE seen in our hospital from January 1993 through March 2003. All patients were diagnosed and followed up at the same institution. The medical records of all affected patients were reviewed using a standardized form to collect clinical information (baseline atherosclerotic risk factors, previous atherosclerotic disease, possible precipitating factors, possible clinical CE-related signs

Patient population

Twenty-six patients with histologically proven CE were identified. All patients were white men (100%). Ages ranged from 48 to 88 years (mean age, 63.7 years). Six patients had peripheral CE (23%) with lower extremity signs without renal or other visceral disease. Twenty patients (77%) had visceral disease with peripheral embolism (17 patients) or without (3 patients). Risk factors for atherosclerosis and the frequency of preexisting atherosclerotic disease are listed in Table I. All patients

Discussion

CE is an increasing cause of morbidity and mortality in the aging, atherosclerotic, white population.11 The characteristics of our patients with multiple risk factors and previous symptomatic atherosclerosis were similar to those reported in previous series.8, 9, 12 Vascular radiologic procedures were the most common precipitating factor in our series, whereas spontaneous CE was uncommon. In early reports, a greater percentage of patients with CE showed a spontaneous form of the disease8, 16;

Conclusion

CE is a not uncommon complication of atherosclerosis that often remains unrecognized because of its nonspecific clinical findings. CE should be strongly considered in elderly patients with atherosclerotic vascular disease and history of a precipitating factor, who develop renal insufficiency and often a sudden onset of livedo reticularis or cyanotic toes. In patients with chronic renal failure, prudence dictates careful evaluation before embarking upon invasive procedures or other precipitating

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    (2003)

    • Cited by (0)

    Funding sources: None.

    Conflicts of interest: None identified.

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    Copyright © 2006 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.