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Cholesterol Embolism Mimic — SCE Rheumatology MCQ

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HardVasculitisCholesterol Embolism MimicSCE Rheumatology

A 72-year-old man with extensive aortic atherosclerosis develops painful blue discoloration of several toes, livedo reticularis, eosinophilia and progressive kidney impairment 3 weeks after coronary angiography. Both dorsalis pedis pulses remain palpable. Primary systemic vasculitis is considered, and a skin biopsy is performed. Which histopathological finding would most strongly establish cholesterol crystal embolisation?

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Correct answer: B — Needle-shaped cholesterol clefts occluding small arterial lumina with a foreign-body giant-cell reaction

The correct answer is B. Cholesterol crystals dissolve during routine tissue processing, leaving characteristic needle-shaped or biconvex clefts within the lumina of small arteries and arterioles. A surrounding foreign-body giant-cell reaction may resemble vasculitis, but the primary lesion is luminal atheroembolism rather than vessel-wall inflammation. The delayed onset after arterial instrumentation, blue toes despite preserved pedal pulses, livedo reticularis, eosinophilia and progressive kidney injury are strongly supportive. Option D describes leukocytoclastic vasculitis; D supports IgA vasculitis; and E suggests eosinophilic granulomatosis with polyangiitis. Granulomatous inflammation centred on an arterial wall, as in B, supports a primary granulomatous arteritis rather than cholesterol embolisation.

Reference: Mehla A, et al. Cholesterol crystal embolization syndrome: Systemic and end-organ injury. American Heart Journal Plus. 2025;59:100612. https://pubmed.ncbi.nlm.nih.gov/41019027/