Cholesterol embolism


The image on the left is an H&E
stained frozen section of a punch
biopsy from the toe.

It shows the profiles of dissolved
cholesterol crystals within a thrombus
in a small artery.

The image on the right is also a frozen
section. It is stained with a Geshickter
stain and examined under polarized light.

The thrombus is pale purple and the 
bright structures in the center are the
actual birefringent cholesterol crystals.

The Geshickter stain is a mixture of
4 parts filtered 1% aqueous Azure A to 
which is added 1 part of filtered 0.5%
Erie Garnet B.  This is mixed and then 

Staining is very rapid.  We routinely use 
this stain to examine serial frozen sections
of the punch biopsy specimen.

2 ribbons of sections are put on each slide and 
10-12 slides, which usually consumes the specimen,
are examined before considering the study negative.

The frozen sections are placed in the Geshickter
stain, immediately, without prior alcohol fixation.
The staining is complete in about 5 seconds.

The slides are rinsed in tap water and covered
with a coverslip using the water droplets on the
surface of the slide.

The slides are examined under polarized light.

We have found this to be a very sensitive technique.

Smaller crystals that may not always be as obvious as 
this example appear as bright, glary, birefringent
crystals in the polarized light. The intravascular
location and crystalline nature are easily determined 
with higher magnification. They may be found in smaller
arterioles or capillaries higher in the dermis in some
cases. H&E stains may not readily detect
these smaller crystal showers that are not 
always associated with obvious intravascular thrombus.

These Geshickter stained slides are not permanent 
so photographs of positive specimens are made. 

In this particular case, there was also 
coagulation necrosis (infarction) of the epidermis. 

Links to PubMed for references

Cutaneous manifestations of cholesterol crystal embolization.
Cholesterol embolization: clinical findings and implications.
Atheromatous embolization precipitated by oral anticoagulants.
Making the diagnosis when the patient has "blue toes".


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