Abstract
A 68-year-old male with a history of arterial hypertension, aneurysm of the aortic arch and heavy smoking was referred to our hospital because of acute renal failure (serum creatinine 7.5 mg/dL, serum urea nitrogen 78 mg/dL). The patient had complained of severe deterioration of his general status with appetite loss and a weight loss of 5 kg over the previous 1 month. Physical examination demonstrated livedo reticularis of the lower legs and cyanosis in the toes (blue toes). Laboratory data showed eosinophilia 1,526/μL. The diagnosis of cholesterol crystal embolism (CCE) was confirmed by biopsy of the skin lesion which demonstrated cholesterol crystals in small arteries. His renal function did not recover during the following days and hemodialysis (HD) was initiated. Twenty-one days after the initiation of HD, the patient was discharged and followed in the outpatient clinic for maintenance HD. However 13 days later, the patient was readmitted because of worsening blue toes with severe pain. His clinical condition worsened progressively and he died of multiple organ failure 27 days after readmission. At autopsy, diffuse erosive atherosclerosis of the aorta was observed and cholesterol crystal emboli were found in the kidneys, lungs, cerebellum, spleen, esophagus, stomach, small intestine and large intestine. CCE in the lung might have been caused by the dialysis arteriovenous fistula (radiocephalic), because there was no atherosclerotic change in the pulmonary and bronchial arteries, and no left-to-right shunting in circulation except for the dialysis arteriovenous fistula. This case suggests that HD requiring systemic anticoagulation deteriorates spontaneous CCE.
