Cutaneous Signs of Vascular Disorders: Cholesterol Emboli

Painful blue toes developed in a 72-year-old woman with coronary artery andperipheral vascular disease after she underwent angiography.Cholesterol emboli or atheromatous emboli develop when cholesterolplaques are dislodged from the aorta or significantly atherosclerotic proximalvessels after catheterization or the Valsalva maneuver. When the entire aorta isatherosclerotic, the fingers as well as the toes may be affected; systemic complications--including stroke, renal failure, pancreatitis, and GI bleeding--mayalso occur. Associated cutaneous findings may include livedo reticularis of thelegs, purpura of the soles and lateral feet, and ulceration and gangrene. A skinbiopsy specimen shows cholesterol crystals within small arterial vessels.The differential diagnosis of blue toes includes emboli from the heart, collagenvascular disease, primary Raynaud phenomenon, thrombocytosis, polycythemia,vasculitis, cryoglobulinemia, macroglobulinemia, and antiphospholipid syndrome.This patient had a concomitant and unrelated morbilliform drug reactionto furosemide affecting the trunk and extremities, including the dorsal feet.