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Cholesterol crystal embolisation — ESENeph MCQ

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HardHypertension and Renovascular DiseaseCholesterol crystal embolisationESENeph

Ten days after coronary angiography, a patient develops rising creatinine, painful blue toes with palpable pulses, livedo reticularis, eosinophilia and low complement. What is the most likely diagnosis?

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Correct answer: C — Cholesterol crystal embolisation following arterial instrumentation

Explanation lettering: B = shown as A · D = shown as B · E = shown as C · C = shown as D · A = shown as E

E is correct. The delayed course after arterial instrumentation, blue toes despite preserved pulses, livedo, eosinophilia and complement consumption form the classic cholesterol-embolisation phenotype. Contrast-associated AKI usually begins within days and does not explain the systemic embolic skin findings. Vasculitis and endocarditis remain differential diagnoses but the trigger and distribution are much more specific here. Interstitial nephritis can cause eosinophilia but not cholesterol-type distal ischaemia. Management is supportive, includes cardiovascular risk reduction and avoidance of further unnecessary arterial instrumentation, and addresses organ complications rather than routine immunosuppression.

Reference: Cholesterol crystal embolisation and kidney disease review: https://pmc.ncbi.nlm.nih.gov/articles/PMC12272466/