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A. Characteristics [3]

  1. Usually occurs in male patients (~75%) with severe atherosclerotic disease
  2. Nearly always (~90%) follows an invasive procedure - days to weeks after procedure
  3. Spontaneous emboli occur mainly in patients with abdominal aortic aneurysms only
  4. Risk Factors [1,6,9]
    1. Atherosclerotic cardiovascular disease
    2. Anticoagulation or thrombolytic therapy
    3. Invasive angiography: cardiac, renal, gastrointestinal "
    4. Cardiopulmonary resuscitation
    5. Hypertension
    6. Hypercholesterolemia
    7. Smoking history
    8. Male Sex / Age over 55 years
    9. Prolonged glucocorticoid therapy may also be a risk factor [8]
  5. Systemic fat emboli may occur in diffuse neoplastic disease, lymphoma [8]
    1. May present with major organ dysfunction
    2. Pulmonary emboli may occur, with severe shortness of breath
  6. Acute renal atheroemboli account for 5-10% of acute renal failure in hospital

B. Symptoms / Signs

  1. Signs of peripheral ischemia without large vessel disease
    1. Blue toes / nail bed infarctions
    2. Livedo reticularis (skin mottling)
    3. Deteriorating renal function
  2. Abdominal Involvement
    1. Mesenteric Ischemia: abdominal pain ± occult Blood positive stool [9]
    2. Pancreatitis
  3. Retinal cholesterol emboli may occur, even with lower extremity instrumentation [7]
  4. Neurologic abnormalities (mononeuritis multiplex picture)
  5. Chest Pain due to myocardial ischemia
  6. Paradoxical embolus: presence of patent foramen ovale or Atrial - Septal Defect (ASD)
  7. Renal failure with minimal or no other symptoms may be present [1]

C. Laboratory

  1. Peripheral eosinophilia [4]
  2. Urinary eosinophilia - usually in patients with cholesterol-renal disease
  3. May have leukocytosis (even >20K/µL) with Left Shift (immature forms)
  4. Organ Specific Damage
    1. Renal Failure - rapidly progressive in many cases [5,10]
    2. Myocardial Infarction - serum creatine kinase (CPK) and troponin elevation
    3. Mesenteric Ischemia - Bloody (OB+) Stool common
    4. Pulmonary fat emboli - severe shortness of breath, difficulty oxygenating [8]
  5. Full septic picture may ensue
    1. Adult Respiratory Distress Syndrome (ARDS) [5]
    2. Microangiopathic hemolysis (disseminated intravascular coagulopathy)
    3. Hypotension is usually a late finding
    4. Fever

D. Treatment [2,3]

  1. Supportive therapy
  2. Consider heparin (concern for increased bleeding)
  3. No definitive therapy at this time; supportive care, fluids
  4. Unclear role for glucocorticoids, even when significant eosinophilia is present

References

  1. Polu KR and Wolf M. 2006. NEJM. 354(1):68 (Case Discussion) abstract
  2. Thibault G. 1993. NEJM. 329(1):38 (Case Discussion) abstract
  3. Moolenaar W and Cornelis BHWL. 1996. Arch Intern Med. 156(5):653
  4. Kasinathy BS and Lewis EJ. 1987. Arch Intern Med. 147:1384 abstract
  5. Stanton RC, Nickeleit V, Mark EJ. 1996. NEJM. 334(15):973 (Case Record)
  6. Mayo RR and Swartz RD. 1996. Am J Med. 100(5):524 abstract
  7. Gittinger JW and Kershaw GR. 1998. Arch Intern Med. 158(11):1265 abstract
  8. Rosen JM and Mark EJ. 1998. NEJM. 339(4):254 (Case Record)
  9. Wong JB and Compton CC. 1998. NEJM. 339(5):329 (Case Record)
  10. Spring MW, Hartley B, Scoble JE, Viberti GC. 1998. Lancet. 352(9132):956 (Case Report) abstract