Case Report

Spontaneous Cholesterol Crystal Embolization to Bone Marrow

Authors: Matthew D. Reuter, MD, Paula J. Chor, MD, Amanda Dehlendorf, MD, Martin A. Alpert, MD

Abstract

Cholesterol crystal embolization is a well-established complication of arterial trauma and anticoagulation which may involve multiple organs including the skin and muscle, producing clinical features such as livedo reticularis, cyanosis and gangrene of the toes and intense myalgias. Cholesterol crystal embolization to bone marrow has been described in postmortem studies, but has been previously reported premortem in only two patients, both of whom had characteristic risk factors and clinical features. We report herein a case of spontaneous cholesterol crystal embolization to bone marrow in a patient with atypical clinical manifestations.


Key Points


* Cholesterol crystal embolization may occur following arterial trauma or anticoagulation.


* Spontaneous cholesterol crystal embolization has been reported.


* The clinical features of cholesterol crystal embolization reflect sites of embolization such as skin and muscle.


* Cholesterol crystal embolization to bone marrow has been reported premortem twice before in patients with characteristic clinical features.


* To our knowledge, this is the first reported case of cholesterol crystal embolization to bone marrow diagnosed premortem in a patient with an atypical clinical presentation.

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References

1. Baumann DS, McGraw D, Rubin BG, et al. An institutional experience with arterial atheroembolism. Ann Vasc Surg 1994;8:258–265.
 
2. Fine MJ, Kapoor W, Falanga V. Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology 1987;38:769–784.
 
3. Pierce JR Jr, Wren MV, Cousar JB Jr. Cholesterol embolism: diagnosis antemortem by bone marrow biopsy. Ann Intern Med 1978;89:937–938.
 
4. Handler FP. Clinical and pathologic significance of atheromatous embolization, with emphasis on an etiology of renal hypertension. Am J Med 1956;20:366–373.
 
5. Gore I, Collins DP. Spontaneous atheromatous embolization. Am J Clin Pathol 1960;33 5:416–426.
 
6. Muretto P, Carevali A, Ansini AL. Cholesterol embolism of bone marrow clinically masquerading as systemic or metastatic tumor. Haemotologica 1991;76:248–250.
 
7. Panum PL. Experimentelle beitrage zur lehre von der embolie. Virchow’s Arch Pathol Anat Physiol1862;25:308–310.
 
8. Flory CM. Arterial occlusions produced by emboli from eroded aortic atheromatous plaques. Am J Pathology 1945;21:549–565.
 
9. Richards AM, Eliot RS, Kanjuh VI, et al. Cholesterol embolism: a multiple-system disease masquerading as polyarteritis nodosa. Am J Cardiol 1965;15:696–707.
 
10. Retan JW, Miller RE. Microembolic complications of atherosclerosis. Arch Intern Med 1966;118:534–545.
 
11. Koga J, Ohno M, Okamoto K, et al. Cholesterol embolization treated with corticosteroids. Angiology 2005;56:497–501.
 
12. Adkinson NF, Younginger JW, Busse WW, et al. In: Middleton’s Allergy: Principles and Practice, Mosby. Philadelphia, 6th edition, 2003:143.
 
13. Moldveen-Geronimus M, Merriam JC Jr. Cholesterol embolization: from pathological curiosity to clinical entity. Circulation 1967;35:946–953.
 
14. Maurizi CP, Barker AE, Trueheart RE. Atheromatous emboli: a postmortem study with special reference to the lower extremities. Arch Pathol 1968;86:528–534.
 
15. Kazmier FJ, Bergan JJ, Yao JST. Aortic Surgery. Philadelphia: WB Saunders, 1989:189–194.
 
16. Belenfant X, Meyrier A, Jacquot C. Supportive treatment improves survival in multivisceral cholesterol crystal embolism. Am J Kidney Dis 1999;33:840–850.