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Cholesterol Embolism: Differential Diagnoses & Workup

Author: Lisa Kirkland, MD, FACP, CNSP, MSHA, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Contributor Information and Disclosures

Updated: Nov 16, 2009

Differential Diagnoses

Abdominal Angina
Gastritis, Stress-Induced
Abdominal Vascular Injuries
Hypertension
Acute Mesenteric Ischemia
Hypertension, Malignant
Acute Respiratory Distress Syndrome
Infective Endocarditis
Adrenal Crisis
Infrainguinal Occlusive Disease
Aortic Dissection
Lower Gastrointestinal Bleeding
Aortoiliac Occlusive Disease
Mesenteric Artery Ischemia
Biliary Colic
Mesenteric Artery Thrombosis
Cardiogenic Shock
Multisystem Organ Failure of Sepsis
Cellulitis
Myocardial Infarction
Deep Venous Thrombosis
Nephritis, Interstitial
Delirium
Pancreatitis, Acute
Diabetic Ulcers
Polyarteritis Nodosa
Encephalopathy, Hypertensive
Upper Gastrointestinal Bleeding
Fournier Gangrene
Gastritis, Acute

Other Problems to Be Considered

Acute Interstitial Nephritis

Workup

Laboratory Studies

  • CBC count
    • Leukocytosis with left shift is nonspecific.
    • Eosinophilia strongly suggests atheroembolization and is present in as many as 80% of patients with cholesterol embolism syndrome.
  • Chemistry: Elevated BUN and creatinine levels are present in virtually all cases of cholesterol embolism syndrome.
  • Urinalysis
    • Microscopic hematuria, proteinuria, and hyaline casts are common.
    • Pyuria actually may be eosinophiluria, a major clue for the diagnosis of cholesterol embolism syndrome.
  • Tissue-specific laboratory tests
    • Muscle injury causes an elevated creatine kinase (CK) level.
    • Myocardial, pancreatic, and hepatobiliary involvement produce increases in cardiac enzymes, amylase, and hepatobiliary enzymes.
  • Inflammatory mediators
    • Nonspecific findings include hypocomplementemia, positive rheumatoid factor, antinuclear antibodies, and elevated C-reactive proteins (CRPs) and sedimentation rates.
    • One study demonstrated a CRP level of >1.0 mg/Dl was an independent predictor of cholesterol emboli in patients with coronary artery disease. (odds ratio, 4.64).

Imaging Studies

  • Angiography
    • Contrast angiography of involved organs may be performed to rule out more treatable causes of tissue ischemia such as polyarteritis nodosa.
    • Angiography may induce atheroembolism.
  • Transesophageal echocardiography
    • Transesophageal echocardiography (TEE) is gaining acceptance as an imaging tool for detecting atheromatous lesions in the ascending and thoracic aorta.
    • Protruding mobile atheromatous masses have been associated with a higher incidence of stroke or cholesterol embolism in patients who undergo cardiac bypass or patients who receive anticoagulants.
    • TEE may eventually be performed in all patients undergoing bypass before aortic cannulation. It also may be performed in all patients with ischemic stroke with an unclear etiology.
  • Dual helical CT
    • Thin sections viewed on nonenhanced dual helical CT may be useful for rapid and noninvasive detection of protruding aortic atheroma.
    • This test can help visualize areas poorly imaged on TEE, such as the distal ascending aorta and arch.
    • One study suggests 87% sensitivity, 82% specificity, and 84% overall accuracy.
  • Magnetic resonance imagery: Little data exist regarding MRI and atheromatous plaque, but a reasonable expectation is that sensitivity is good.

Procedures

  • Tissue biopsy
    • Demonstration of cholesterol crystals in occluded arterioles is the only definitive test for cholesterol embolism.
    • Skin, renal, muscle, or GI tract biopsy may reveal crystal ghosts inside vessels.
    • Often, multiple samples may be necessary to demonstrate the crystals.

Histologic Findings

The actual cholesterol crystals are dissolved during fixation, leaving intra-arterial biconvex ghosts. Often, the crystals are missed because the depth of the tissue sample is inadequate. If these ghosts are absent, the diagnosis still may be inferred by fibrinoid necrosis (see Image 2) and a foreign-body reaction in tissues commonly involved by atheromatous emboli in a patient with consistent clinical findings. Exuberant adventitial fibrosis contributes to vessel lumen occlusion.

Necrosis of the abdominal wall in a patient with ...

Necrosis of the abdominal wall in a patient with cholesterol embolism syndrome who received anticoagulation.

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Necrosis of the abdominal wall in a patient with ...

Necrosis of the abdominal wall in a patient with cholesterol embolism syndrome who received anticoagulation.


More on Cholesterol Embolism

Overview: Cholesterol Embolism
Differential Diagnoses & Workup: Cholesterol Embolism
Treatment & Medication: Cholesterol Embolism
Follow-up: Cholesterol Embolism
Multimedia: Cholesterol Embolism
References
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References

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Further Reading

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Keywords

cholesterol, embolism, cholesterol embolism, cholesterol embolism syndrome, CES, atheroembolism, trash foot syndrome, hypertension, HT, distal ischemia, cholesterol crystals, cholesterol plaques, atherosclerotic plaque, atheroembolic events

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Contributor Information and Disclosures

Author

Lisa Kirkland, MD, FACP, CNSP, MSHA, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Travis J Phifer, MD, Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport
Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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