From the Guidelines
Cholesterol embolism to the toes typically presents as blue or purple discoloration (livedo reticularis), pain, and tenderness in the affected toes, and may be accompanied by symptoms such as sudden onset of severe pain, skin changes, and renal dysfunction, as noted in patients with atherosclerotic disease 1.
Presentation of Cholesterol Embolism
The condition often occurs following vascular procedures, anticoagulation therapy, or thrombolysis in patients with atherosclerotic disease. Patients may develop small, painful nodules called "trash foot" or "blue toe syndrome" with intact pulses.
- Symptoms may include:
- Sudden onset of severe pain
- Skin changes ranging from mottling to gangrene
- Renal dysfunction
- Gastrointestinal symptoms
- Mental status changes
Diagnosis and Management
Diagnosis is primarily clinical but may be supported by elevated inflammatory markers, eosinophilia, decreased renal function, or skin biopsy showing cholesterol clefts, as described in the management of peripheral artery disease 1.
- Management focuses on:
- Treating the underlying atherosclerotic disease with statins and antiplatelet therapy
- Avoiding anticoagulation which can worsen the condition
- Controlling pain
- Providing supportive care
- In severe cases, amputation may be necessary for non-healing ulcers or gangrene, as noted in the guidelines for the management of lower extremity peripheral artery disease 1. The prognosis varies depending on the extent of embolization and underlying vascular disease, highlighting the importance of prompt diagnosis and treatment to prevent morbidity and mortality 1.
From the Research
Presentation of Cholesterol Embolism to the Toes
Cholesterol embolism to the toes can present in various ways, including:
- Purple discoloration and ulceration of the toes, as seen in a case report of a 74-year-old male who developed these symptoms two months after coronary artery bypass surgery 2
- Blue toes, which can be a part of a broader differential diagnosis, as reported in a case of cholesterol crystal embolism diagnosed by skin and renal biopsies 3
- Livedo reticularis and pain from the acrocyanotic toes, which dramatically improved after low-density lipoprotein apheresis (LDL-A) in a patient with hypertension and diabetes mellitus 3
- Gangrene of the toes with intact pulses, as described in a review of the cholesterol emboli syndrome 4
Clinical Manifestations
The clinical manifestations of cholesterol embolism to the toes can be part of a larger syndrome, which may include:
- Renal failure, as reported in several cases of cholesterol emboli syndrome 3, 4, 5
- Global neurologic deficits, as described in a review of the cholesterol emboli syndrome 5
- Gastrointestinal, ocular, and constitutional signs and symptoms, which can occur due to the systemic nature of the disease 5
Diagnosis and Treatment
Diagnosis of cholesterol embolism to the toes can be based on:
- Biopsy of the affected tissue, which can reveal cholesterol crystals in the arterial lumen, as seen in a case report of a 74-year-old male 2
- Skin and renal biopsies, which can confirm the diagnosis of cholesterol crystal embolism, as reported in a case study 3 Treatment of cholesterol embolism to the toes remains largely supportive and prophylactic, with options including:
- Topical amitriptyline ketamine, which improved toe pain in a case report of a 74-year-old male 2
- LDL-A, which dramatically improved skin lesions and renal function in a patient with hypertension and diabetes mellitus 3
- Corticosteroids and angiotensin II type 1 receptor antagonists (ARBs), which improved renal function and reduced urinary protein excretion in a case study 3