Three days after femoral angiography, a 68-year-old man develops livedo reticularis over both legs, bluish discoloration of the toes, abdominal pain, and a creatinine rising from 1.2 to 3.4 mg/dL. Total leukocyte count shows 15% eosinophils, ESR is 72 mm/hr, and complement C3 is low. Skin biopsy of a toe shows elongated needle-shaped clefts in arterioles. What is the most likely diagnosis?

• A Iodinated contrast-induced acute tubular necrosis
• B Atheroembolic (cholesterol crystal) renal disease ✓
• C Polyarteritis nodosa
• D ANCA-associated small vessel vasculitis

Explanation

Atheroembolic disease follows dislodgement of cholesterol crystals from plaques during arterial instrumentation, typically presenting days to weeks later with livedo reticularis, blue toes, abdominal pain, eosinophilia, low complement, and slowly progressive renal failure. Biopsy shows biconvex needle-shaped clefts where crystals dissolved during processing. Contrast nephropathy peaks within 24 to 48 hours and causes no cutaneous signs, while polyarteritis nodosa lacks the pathognomonic cholesterol clefts on biopsy.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.