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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 82-year-old man was admitted to our Dermatology Department for necrotic skin lesions on the limbs with a 4-month evolution&#46; He was diagnosed a coronary disease by coronary angiography made six months earlier&#46; He had also hypertension&#44; hypercholesterolemia&#44; and was anticoagulated with warfarin for atrial fibrillation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The physical examination revealed purpuric papules and plaques with a necrotic center in the upper and lower limbs&#44; including fingers and toes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Erosions of the nasal mucosa were also observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Laboratory testing was unremarkable&#44; including autoimmunity &#40;tests for antinuclear and anti-neutrophil cytoplasm antibodies were negative&#41;&#44; viral serologies &#40;HIV&#44; HBV&#44; HCV&#41;&#44; serum protein electrophoresis&#44; and cryoglobulins&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Skin biopsy showed biconvex&#44; needle-shaped clefts inside the arterioles of the dermis&#44; without signs of vasculitis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Direct immunofluorescence of perilesional skin was negative</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">What is the Diagnosis&#63;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Obstructive Vasculopathy by Cholesterol Crystal Emboli &#40;CCE&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The oral anticoagulant was withdrawn&#46; Treatment for this patient included oral prednisolone &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; and statins&#44; with progressive improvement of the cutaneous lesions&#46; Unfortunately&#44; the patient died of nosocomial pneumonia one month later&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Comments</span><p id="par0040" class="elsevierStylePara elsevierViewall">CCE is one of the complications of atherosclerosis&#46; It usually occurs after a precipitating event&#44; such as endovascular procedures&#44; or in association with anticoagulant therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Virtually&#44; all organs can be affected&#46; A variety of clinical manifestations&#44; ranging from asymptomatic to life-threatening&#44; may be observed and are generally nonspecific&#46; Consequently&#44; the diagnosis of CCE is frequently a challenge&#44; because often it simulates other diseases&#46; Despite not being uncommon&#44; it is still an under-recognized disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The frequency of cutaneous findings in CCE varies from 35&#37; to 96&#37;&#46; They include livedo reticularis&#44; gangrene&#44; cyanosis&#44; ulceration&#44; nodules&#44; and purpura&#44; which mainly occur on the lower limbs&#46; The differential diagnoses include infectious&#44; inflammatory&#44; and vascular conditions&#44; particularly embolic&#44; coagulopathic&#44; or vasculitic diseases that should warrant a skin biopsy as part of the diagnostic workup&#46; Therefore&#44; the presence of skin involvement&#44; more than any other&#44; should facilitate the diagnosis of CCE&#46; Skin biopsies are fairly sensitive for CCE by showing the hallmark of cholesterol clefts within the arterioles in 92&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The prognosis of CCE is poor&#44; with mortality as high as 81&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">There is no specific treatment for CCE&#46; However&#44; aggressive supportive care has been shown to have a significant benefit&#46; Ceasing anticoagulation is recommended&#46; The benefit of steroids and statins has been suggested&#44; but it is still unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although CCE frequently presents as a multisystemic disease&#44; it may also manifest only in the skin&#44; similar to our case&#44; which underlines the importance of the dermato&#40;patho&#41;logist on the correct diagnosis of this condition&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare not to have any conflict of interest&#46;</p></span></span>"
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