A 68-year-old woman with type 2 diabetes mellitus is hospitalized for an acute ST-segment elevation myocardial infarction. She undergoes immediate cardiac catheterization and successful stenting of the mid-left anterior descending artery. The patient is treated with aspirin, prasugrel, metoprolol, lisinopril, and rosuvastatin. On the third day of hospitalization, she complains of vague abdominal pain. Her blood pressure is 122/70 mm Hg and pulse is 62/min. Lungs are clear to auscultation. There are no cardiac murmurs. Her abdomen is soft and mildly tender in the periumbilical area. Bilateral pedal pulses are full and symmetric. There is bluish discoloration of her right great toe and all the toes on her left foot. She has additional skin findings as shown below: Serum creatinine is 2.3 mg/dL (1.1 mg/dL on admission). Electrocardiogram (ECG) shows sinus rhythm and Q waves in anterior leads. Which of the following is the most likely cause of this patient's symptoms?

Question

A 68-year-old woman with type 2 diabetes mellitus is hospitalized for an acute ST-segment elevation myocardial infarction.  She undergoes immediate cardiac catheterization and successful stenting of the mid-left anterior descending artery.  The patient is treated with aspirin, prasugrel, metoprolol, lisinopril, and rosuvastatin.  On the third day of hospitalization, she complains of vague abdominal pain.  Her blood pressure is 122/70 mm Hg and pulse is 62/min.  Lungs are clear to auscultation.  There are no cardiac murmurs.  Her abdomen is soft and mildly tender in the periumbilical area.  Bilateral pedal pulses are full and symmetric.  There is bluish discoloration of her right great toe and all the toes on her left foot.  She has additional skin findings as shown below:  Serum creatinine is 2.3 mg/dL (1.1 mg/dL on admission).  Electrocardiogram (ECG) shows sinus rhythm and Q waves in anterior leads.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

This patient most likely has atheroembolism (cholesterol embolism) caused by recent cardiac catheterization. Atheroembolism occurs when an atherosclerotic plaque is disrupted and cholesterol crystals and debris are showered into the circulation. This leads to partial or total occlusion of arterioles with resultant tissue or organ ischemia. Risk factors for atheroembolism are advanced age, obesity, smoking, hypercholesterolemia, hypertension, and diabetes. Atheroembolism is most commonly seen as a complication of cardiac catheterization and other vascular procedures. Clinical manifestations can be immediate or delayed (>30 days after inciting event). Atherosclerotic plaques in the aortic arch can embolize to the brain and cause cerebral infarction. Diffuse showering of emboli into the peripheral circulation can cause intestinal ischemia, gastrointestinal bleeding, pancreatitis, and acute kidney injury. Skin manifestations are the most common complication (34% of patients) and include "blue toe syndrome" (cyanotic toes with intact pulses), livedo reticularis (reticular, lacy skin discoloration/erythema that blanches on pressure), gangrene, and ulcers. Examination of the retina may show Hollenhorst plaques, bright, yellow, refractile plaques in the retinal artery, which indicate a proximal source such as the internal carotid artery. > livedo reticularis Treatment of atheroembolism is primarily supportive. Atheroembolism also reinforces the indication for statin therapy in patients with atherosclerotic vascular disease. Some patients may have renal dysfunction that persists beyond 2 weeks (compared to contrast nephropathy, which usually resolves within 1 week). (Choice A) Vasospasm is not a common complication of cardiac catheterization and is an unlikely cause of this patient's toe discoloration, abdominal pain, and elevated creatinine. (Choices B and D) Allergic reactions to iodine typically occur in patients with prior history of contrast reactions or atopic diseases (eg, asthma). Immediate reactions may cause flushing, pruritus, or angioedema; delayed hypersensitivity reactions can present days after iodide administration with various cutaneous manifestations. However, the combination of cyanotic toes, abdominal pain, and renal failure post-cardiac catheterization is most suggestive of atheroembolism. Similarly, although autoimmune vasculitis can cause cyanosis and renal injury, the timeline of presentation suggests atheroembolism. (Choice E) Right-to-left shunts deliver deoxygenated blood to the systemic circulation and result in hypoxemia and cyanosis. Cyanosis is often diffuse (eg, fingers, toes, lips) and accompanied by digital clubbing. (Choice F) The most common side effects of angiotensin-converting enzyme inhibitors include cough, increased serum creatinine (often transient), and hyperkalemia. Angioedema is a rare complication and presents with asymmetric nonpitting swelling of the lips, tongue, face, or larynx (causing airway obstruction). Visceral angioedema (affecting the small intestine) can occur and typically presents with abdominal pain, ascites, vomiting, and diarrhea. Educational objective: Atheroembolism (cholesterol embolism) is a complication of cardiac catheterization and other vascular procedures. It is characterized by cutaneous findings (eg, "blue toe syndrome," livedo reticularis), cerebral or intestinal ischemia, acute kidney injury, and Hollenhorst plaques. Treatment is supportive and includes statin therapy for risk factor reduction and prevention of recurrent cholesterol embolism. References: The cholesterol emboli syndrome in atherosclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/23423524) Use of corticosteroids in the treatment of cholesterol crystal embolism after cardiac catheterization: a report of four Japanese cases. (http://www.ncbi.nlm.nih.gov/pubmed/23648720)

A 68-Year-Old Woman with Type 2 Diabetes Mellitus Is Hospitalized