Abstract
A 76-year-old male with a history of pulmonary hypertension, diabetes mellitus, hypertension, hyperlipidemia, and old cardiac infarction was admitted to our hospital due to transient unconsciousness and diagnosed with pulmonary embolism (PE). He underwent inferior vena cava filter (IVC filter) application and anticoagulant therapy (Warfarin sodium at 3mg/day, etc.). His baseline creatinine value of 1.1mg/dL had risen to 7.7mg/dL 19 days after admission. Physical examination demonstrated constitutional erythema with itching and purpura of the toes (blue toes). We performed a skin biopsy and diagnosed him with cholesterol crystal embolism (CCE). Predonisolone (PSL) at 40mg/day and LDL apheresis decreased the creatinine level and we tapered the PSL dose. However, gradually, the patient complained of appetite loss and showed deterioration of renal failure, and so hemodialysis (HD) was initiated 48 days after admission. At 269 days from the initiation of HD, the patient complained of chest pain, and was diagnosed with relapse of PE. He died of PE the next day even though he underwent IVC filter use again and anticoagulation therapy (heparin: 20,000 units/day and Warfarin sodium: 2mg/day). At autopsy, numerous organizing blood clots were observed in the pulmonary arteries, and relatively new ones were in the superior lobe branch of the right lung. Cholesterol crystal (CC) emboli were found in the renal interlobular arteries. The lumens of arteries were obstructed by proliferative connective tissue. CCs were also observed in the subcutaneous tissue, liver, pancreas, adrenal gland, and spleen. It was a difficult case to treat as both PE and CCE were involved, requiring therapies contradictory to each other.
