Spontaneous cutaneous cholesterol crystal embolism with focal clinical symptomatology: report of a case in an unusual location with secondary histological changes reminiscent of atypical decubital fibroplasia

Abstract

Cholesterol crystal embolization (CCE) is one of the many complications of atherosclerosis. CCE is usually an iatrogenic event occurring either after vascular surgery, usually aortic surgery, or invasive angiographic investigations or in the course of anticoagulant or thrombolytic therapy. More rarely, it occurs after trauma or even in the absence of any inciting cause. CCE may manifest with single or multiorgan involvement. Skin involvement is usually seen in the context of a systemic disease, especially affecting the lower extremities and lower trunk. We report on a rare case of isolated spontaneous focal cutaneous involvement of the upper limb, with peculiar mesenchymal and reactive histological changes. A 65-year-old man with a clinical history of atherosclerosis was admitted complaining of a nonhealing painful skin ulceration on his left elbow for 5-month duration. A skin biopsy was taken, and histopathological examination documented an intrarteriolar cholesterol embolus in the dermis along with a peculiar adjacent bizarre fibroblastic reaction, of the type usually seen in atypical decubital fibroplasia of debilitated patients. The ulceration was surgically excised, and the wound was sutured and repaired. At 18-month follow-up, the patient has no evidence of local disease.