Cholesterol Crystal Embolism — ESENeph MCQ

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ModerateAcute Kidney InjuryCholesterol Crystal EmbolismESENeph

A 70-year-old man with CKD G5D on haemodialysis develops painful purple discolouration of his toes bilaterally. He has palpable pedal pulses. He recently underwent cardiac catheterisation via the femoral artery 3 weeks ago. Eosinophilia is present. His creatinine has risen further. What is the diagnosis?

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Correct answer: C — Cholesterol crystal embolism (atheroembolic disease)

Purple/blue toes with palpable pulses after an arterial procedure (catheterisation, vascular surgery), combined with eosinophilia, elevated ESR, and worsening renal function, is classic for cholesterol crystal embolism (atheroembolic disease). Cholesterol crystals from disrupted aortic plaque shower into small vessels causing end-organ damage. Biopsy shows biconvex clefts (cholesterol crystals dissolved during processing). Livedo reticularis is another cutaneous finding. There is no specific treatment – supportive care and secondary prevention. Anticoagulation is controversial (may worsen embolisation).

Reference: KDIGO 2012 – AKI; Scolari et al 2018 – Cholesterol Embolism Review