An Unusual Place to Land! Cholesterol Crystal Embolization to the Kidney and Duodenal Leiomyoma

Abstract

A 69-year-old man with history of CAD admitted for melena without abdominal pain. He had triple vessel CABG 2 months ago. Physical examination revealed pale palpebral conjunctiva and non-tender abdomen. Initial laboratories were depicted in table 1. The patient was started on pantoprazole drip and PRBCs were transfused. After stabilization of his hemodynamics, EGD was done revealing a large, subepithelial mass with ulcerated center, arising from the 2nd portion of the duodenum. CT abdomen and EUS revealed an exophytic solid mass arising from the muscularis propia of the duodenum. FNA biopsy revealed a spindle cell neoplasm. Immunohistochemical stains were compatible with a leiomyoma. Surgery was deferred because of increasing renal functions. Renal biopsy revealed multiple intra-luminal clefts and spaces within the glomerulus consistent with renal cholesterol embolic disease. His creatinine eventually stabilized and thus, surgery was done. Gross pathology revealed a tan-pink irregular ovoid shaped mass measuring 9 cm with a smooth surface, prominent vasculature and a 2.5 x 1.5 cm central ulcer. Microscopic examination confirmed leiomyoma with large submucosal blood vessels containing multiple intra-luminal clefts and spaces consistent with cholesterol emboli. Patient did well however, his renal functions did not return to his baseline. Cholesterol crystal emboli (CCE) are migrations of cholesterol crystals from ulcerated arterial atherosclerosis plaques resulting in tissue ischemia and necrosis. Microscopically, the crystals dissolve during the histotechnical procedure, leaving pathognomonic needle shaped lacunae in the lumina of arterioles. The risk of cholesterol crystal formation is directly related to the severity of atherosclerosis. Risk factors for embolization include the presence of an abdominal aortic aneurysm, endovascular instrumentation and anticoagulation or thrombolytic therapy. CCE can occur in any organ. In the gastrointestinal system, the colon and small bowel are most commonly affected. However, embolization to a duodenal leiomyoma is uncommon. Gastrointestinal involvement presents as abdominal pain, bleeding, colitis, ileus or intestinal obstruction. Treatment includes management of risk factors and end-organ ischemia. Anticoagulation therapy is controversial. The prognosis in medically treated patients is poor. Mortality rates may be as high as 80 percent when post-mortem diagnoses are included.Table: Table. Laboratory workup