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Ateroembolismo num doente submetido a um cateterismo cardíaco : caso clínico
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Um homem de 60 anos, ex-fumador e com antecedentes de hipertensão arterial e cardiopatia isquémica, inicia um quadro de náuseas, diarreia intermitente e lesão renal aguda. Posteriormente apresentou também cefaleias, perda ponderal, hipertensão arterial refratária à terapêutica, livedo reticularis e isquémia dos membros inferiores com ulceração digital. Cerca de um mês antes do início do quadro realizou um cateterismo cardíaco. A avaliação analítica revelou eosinofilia, elevação da ureia e da creatinina séricas, aumento da velocidade de sedimentação eritrocitária e elevação da proteína C reactiva. Depois de uma extensa investigação diagnóstica foi realizada uma biópsia renal cujo exame anatomopatológico mostrou fissuras biconvexas no lúmen das arteríolas renais, sendo colocado o diagnóstico ateroembolismo. Através da realização de fundoscopia ocular detectaram-se também êmbolos de colesterol na retina. O doente realizou terapêutica com anti-hipertensores, corticóides, ciclofosfamida, heparina, pentoxifilina, alprostadilo e cloridrato de buflomedil, bem como amputação de um dedo do pé. Teve alta após 66 dias de internamento, depois de atingida a estabilização da função renal. Com este caso clínico exemplifica-se uma complicação grave, embora ainda pouco conhecida e muitas vezes subdiagnosticada, dos procedimentos vasculares invasivos, cuja apresentação clínica pode ser diferida no tempo em relação ao cateterismo e mimetiza frequentemente um quadro de vasculite sistémica.
A 60-year-old man, former smoker, with history of arterial hypertension and ischemic heart disease, presents with nausea, intermittent diarrhea and acute renal failure. Later he presented headache, weight loss, refractory arterial hypertension, livedo reticularis and lower limb ischemia with digital ulceration. A month before the beginning of the symptoms the patient was submitted to a heart catheterization. On evaluation, he had eosinophilia, increased blood levels of urea and creatinine, elevated erythrocyte sedimentation rate and C-reactive protein levels. After a thorough diagnostic investigation a kidney biopsy was performed. The histopathologic examination revealed biconvex clefts in the lumen of the renal arterioles allowing the diagnosis of atheroembolism to be made. On retinal examination cholesterol emboli were detected. The patient was medicated with antihypertensive drugs, corticosteroids, cyclophosphamide, heparin, pentoxifylline, alprostadil, buflomedil chlorhydrate, and a toe amputation was performed. He was discharged after 66 days at the hospital with a stabilized renal function. This case report shows a serious and underdiagnosed complication of the invasive vascular procedures, with a clinical presentation that can be deferred in time in relation to the heart catheterization and frequently mimics a systemic vasculitis.
A 60-year-old man, former smoker, with history of arterial hypertension and ischemic heart disease, presents with nausea, intermittent diarrhea and acute renal failure. Later he presented headache, weight loss, refractory arterial hypertension, livedo reticularis and lower limb ischemia with digital ulceration. A month before the beginning of the symptoms the patient was submitted to a heart catheterization. On evaluation, he had eosinophilia, increased blood levels of urea and creatinine, elevated erythrocyte sedimentation rate and C-reactive protein levels. After a thorough diagnostic investigation a kidney biopsy was performed. The histopathologic examination revealed biconvex clefts in the lumen of the renal arterioles allowing the diagnosis of atheroembolism to be made. On retinal examination cholesterol emboli were detected. The patient was medicated with antihypertensive drugs, corticosteroids, cyclophosphamide, heparin, pentoxifylline, alprostadil, buflomedil chlorhydrate, and a toe amputation was performed. He was discharged after 66 days at the hospital with a stabilized renal function. This case report shows a serious and underdiagnosed complication of the invasive vascular procedures, with a clinical presentation that can be deferred in time in relation to the heart catheterization and frequently mimics a systemic vasculitis.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2016
Palavras-chave
Ateroembolismo Embolia de Colesterol Cateterismo cardíaco Colesterol