Tohoku J. Exp. Med., 2020 May, 251(1)

Cholesterol Emboli Co-Existing with Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis in a 76-Year-Old Woman

RISA KOJIMA,¹ MAKOTO HARADA,¹ AKINORI YAMAGUCHI,¹ KOJI HASHIMOTO¹ and YUJI KAMIJO¹

¹Department of Nephrology, Shinshu University Hospital, Matsumoto, Nagano, Japan

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis injures small vessels and causes severe systemic organ injury. Main target antigens of ANCA are myeloperoxidase and proteinase 3. ANCA strongly associates with the development and progression of the vasculitis. Its manifestations include rapidly progressive glomerulonephritis, interstitial pneumonitis, alveolar hemorrhage, purpura, and neurological disorder. Most patients with ANCA-associated vasculitis in Japan are elderly and have atherosclerotic risk factors. Cholesterol emboli are systemic vascular inflammation triggered by cholesterol crystals. Cholesterol emboli cause kidney dysfunction and ischemia of the intestines, brain, heart, skin, and peripheral nerves. Diabetes mellitus, hypertension, hyperlipidemia, and history of cardiovascular diseases are risk factors of the development of cholesterol emboli. We report a case of ANCA-associated vasculitis coexisting with cholesterol emboli. A 76-year-old woman was diagnosed with ANCA-associated interstitial pneumonitis. She rapidly developed progressive glomerulonephritis, purpura, and peripheral sensory nerve disorder. A kidney biopsy revealed that renal dysfunction was caused by vasculitis of the interlobular arteries and cholesterol emboli. A skin biopsy revealed that purpura was caused by cholesterol emboli. Glucocorticoid and statin therapies were administered. Thereafter, the renal function and other symptoms improved and stabilized. The representative symptoms of ANCA-associated vasculitis and cholesterol emboli are closely similar, and it is difficult to distinguish between these diseases when they coexist. Because the background characteristics of patients with ANCA-associated vasculitis and risk factors of cholesterol emboli overlap, at the time of diagnosing ANCA-associated vasculitis, clinicians should consider the possibility of cholesterol emboli coexistence.

Keywords —— anti-neutrophil cytoplasmic antibody; anti-neutrophil cytoplasmic antibody-associated vasculitis; cholesterol emboli; purpura; rapidly progressive glomerulonephritis

© 2020 Tohoku University Medical Press

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Tohoku J. Exp. Med., 2020, 251, 61-68

Correspondence: Makoto Harada, M.D., Ph.D., Department of Nephrology, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan.

e-mail: tokomadaraha724@gmail.com