The systemic immune response due to cholesterol crystal embolization syndrome: a case report

Tetsu Sakamoto, Takafumi Yamakawa, Keita Hirano, Arisa Kobayashi, Mio Kasai, Kiyoshi Koizumi, Takashi Yokoo, Satoru Komatsumoto, Toshimitsu Murohisa, Taro Shimizu

Research output: Contribution to journalArticlepeer-review


Background: Cholesterol crystal embolization syndrome (CES) occurs when an atherosclerotic plaque causes small-vessel embolization, resulting in multi-organ damage. Although CES is pathologically characterized by an infiltration of eosinophils, the implication of the systemic inflammatory response represented by hypereosinophilia is unclear in clinical practice. Herein we present the case of a patient diagnosed with CES who developed multiple allergic organ injuries, including daptomycin-related dermatitis and later vancomycin-induced acute tubulointerstitial nephritis, which was successfully treated by the withdrawal of each medicine with or without corticosteroid therapy, one by one. Case presentation: A 76-year-old Japanese man diagnosed with thoracic aneurysm rupture underwent total arch replacement through the open stent graft technique. Postoperatively, he developed methicillin-resistant Staphylococcus epidermidis bacteremia, which was treated with daptomycin. Subsequently, he presented with palpable purpura on both dorsal feet, erythema around his body, and hypereosinophilia. Daptomycin was replaced with vancomycin due to suspicion of drug-induced erythema. The erythema gradually faded. On nine days after vancomycin therapy, the systemic erythema rapidly reappeared followed by acute renal failure. The renal function decline prompted hemodialysis. A skin biopsy revealed cholesterol embolization, whereas a kidney biopsy revealed acute tubulointerstitial nephritis. After vancomycin discontinuation and initiation of systemic corticosteroid treatment, his kidney function was restored to the baseline level. Conclusions: The present case highlights cholesterol embolization can cause allergic complications in addition to direct organ damage.

Original languageEnglish
Article number314
JournalBMC Nephrology
Issue number1
Publication statusPublished - 12-2022
Externally publishedYes

All Science Journal Classification (ASJC) codes

  • Nephrology


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