Case 1

A 75 year old Indian Asian man presented to his local hospital with unstable angina where he received conventional treatment with intravenous nitrates and heparin. His pain subsided but he subsequently developed recurrent episodes of “flash” pulmonary oedema and recalcitrant hypertension. These were accompanied by an inexorable decline in renal function over four weeks until eventually he became dependent on dialysis.

Severe hypertension and signs of peripheral vascular disease were found on physical examination, but there were no audible renal bruits. Non-blanching purpuric lesions suggestive of embolisation were noted on his toes. Blood tests showed a marked peripheral blood eosinophilia of 0.59 × 109/l (normal range <0.40) and a C3 complement component just below the lower limit of normal, at 0.59 g/l (normal range 0.6-1.6). An angiogram performed using spiral computed tomography showed an atheromatous aorta but no evidence of renal artery stenosis. A percutaneous renal biopsy showed clefts in the lumen of intrarenal arterioles, confirming a diagnosis of cholesterol embolism.

The patient later underwent coronary angioplasty for treatment of intractable angina. He died within 72 hours after massive gastrointestinal bleeding, probably the result of fresh cholesterol embolisation.

Case 2

A 62 year old man …