A 60-year-old man comes to the physician due to nausea and abdominal pain. He had a coronary angiogram and stent placement for chest pain 5 days ago and was discharged home the day after the procedure. His other medical problems include hypertension, hypercholesterolemia, peripheral artery disease, and type 2 diabetes mellitus. Physical examination shows painless, purple mottling of the skin of both feet. Laboratory results are as follows: Which of the following is the most likely cause of this patient's findings?

Question

A 60-year-old man comes to the physician due to nausea and abdominal pain.  He had a coronary angiogram and stent placement for chest pain 5 days ago and was discharged home the day after the procedure.  His other medical problems include hypertension, hypercholesterolemia, peripheral artery disease, and type 2 diabetes mellitus.  Physical examination shows painless, purple mottling of the skin of both feet.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's findings?

Quizplus · Accepted Answer

11ec25c8_d335_86e9_bc81_2509de3078c9_MD0003_00 This patient's clinical presentation is consistent with systemic atheroembolism from disruption of atherosclerotic aortic plaques (cholesterol crystal embolism). Aortic atherosclerotic plaques occur in patients with risk factors for atherosclerosis (eg, hypertension, hypercholesterolemia, diabetes) and can lead to systemic emboli (cerebral, visceral, or lower extremity). Embolism can happen spontaneously, but occurs more commonly during vascular procedures such as peripheral angiography or interventions, guidewire or catheter manipulations during cardiac catheterization, and intraaortic balloon pump insertion. The diagnosis should be suspected in patients with a constellation of acute/subacute renal failure, typical skin manifestations, and/or gastrointestinal symptoms (eg, nausea, abdominal pain) after a recent vascular procedure. Livedo reticularis is a reticular, erythematous or purple discoloration of the skin that blanches when pressure is applied; in patients with cholesterol emboli, it is typically seen bilaterally in the lower extremities (due to embolization to the vessels). Laboratory studies may show eosinophilia/uria (due to interleukin-5 activation) as well as hypocomplementemia (likely due to neutrophil activation) in cases of recent atheroembolism. Urinalysis is typically benign, with few cells or casts. When the diagnosis remains unclear, skin or renal biopsy may be performed for confirmation. Livedo reticularis (Choice B) Patients undergoing coronary angiography are at risk for contrast-induced nephropathy (CIN). Urinalysis in CIN typically shows muddy-brown granular and epithelial cell casts. CIN usually begins to resolve within 3-5 days; renal atheroembolism often shows delayed-onset kidney injury. Moreover, CIN is not associated with multisystem involvement, which favors the diagnosis of cholesterol embolization. (Choice C) Crescentic glomerulonephritis can lead to rapid onset of renal failure and is usually accompanied by active urinary sediment with hematuria and red cell casts. This patient's presentation of multisystem involvement, eosinophilia, low complement levels, and benign urinalysis makes cholesterol embolization a more likely diagnosis. (Choice D) Diabetic nephropathy usually results in slowly progressive renal failure with predominant albuminuria or proteinuria. (Choice E) Urinary tract obstruction typically causes oliguria and renal failure with increased blood urea nitrogen and serum creatinine. Educational objective: Cholesterol embolization should be suspected in patients with multisystem involvement with acute or subacute renal failure, typical skin manifestations (eg, livedo reticularis, blue toe syndrome), cerebral or intestinal ischemia, and Hollenhorst plaques after recent arteriography or cardiac catheterization. References: Atheroembolic renal disease. (http://www.ncbi.nlm.nih.gov/pubmed/20381857) Atheroembolic renal failure after invasive procedures. natural history based on 52 histologically proven cases. (http://www.ncbi.nlm.nih.gov/pubmed/7500898) Cholesterol crystal embolism: a recognizable cause of renal disease. (http://www.ncbi.nlm.nih.gov/pubmed/11096032)

A 60-Year-Old Man Comes to the Physician Due to Nausea