A 47-year-old hypertensive woman was admitted to the Intensive Care Unit due to abdominal pain and shock with violet macular skin rash (Fig. 1). Laboratory testing revealed normal leukocyte and renal function values, with lactic acid 4.4mmol/l. The abdominal CAT scan revealed splenic, pancreatic and focal hepatic attenuation. Emergency laparotomy was performed, revealing multivisceral infarcts and necrosis. Splenectomy, distal pancreatectomy and gastrectomy were performed. The biopsy revealed the presence of cholesterol crystal emboli (CCE) (Fig. 2). Full patient recovery was achieved. The mortality rate of CCE can reach 65%. Affected patients usually have a history of cardiovascular procedures or anticoagulant-fibrinolytic treatments, which was not seen in our patient. We present an infrequent case of spontaneous CCE manifesting as livedo reticularis and multivisceral infarcts. The skin involvement can suggest CCE, though vasculitis and neoplastic processes must be discarded. The skin lesion biopsy can confirm the diagnosis and facilitate curative surgical management.

Figure 1.

Image of livedo reticularis on the lower extremities, first 24h of admission. Skin involvement comprising the upper abdomen, hips, buttocks and both feet, with “blue toes”. The image at top shows drainage after emergency laparotomy with splenectomy, gastrectomy and pancreatectomy due to multivisceral infarcts.

Figure 2.

Histopathology: cholesterol crystals within the lumen of the small arterioles. (A) Gastric. (B) Splenic. (C) Pancreatic. (D) Cutaneous (hematoxylin–eosin, 10×).