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Alwattar-Ceballos O, Martínez-Montalvo L, Montero-García M, Gómez-Manzanares M, Arambarri-Segura M. Blue toe syndrome due to crystal cholesterol embolism. Med Clin (Barc) 2024; 162:407. [PMID: 38042736 DOI: 10.1016/j.medcli.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Omar Alwattar-Ceballos
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España.
| | - Laura Martínez-Montalvo
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Marina Montero-García
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Mónica Gómez-Manzanares
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
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2
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Casado-Hoces SV, González-Tejedor D, Domínguez-García MA, Reina-Herraiz B. Blue toe syndrome. Rev Esp Sanid Penit 2023; 25:122-124. [PMID: 38289167 PMCID: PMC10910321 DOI: 10.18176/resp.00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 05/25/2023] [Indexed: 02/01/2024]
Affiliation(s)
- Sofía Victoria Casado-Hoces
- Specialist Nurse in Family and Community Medicine. Madrid III-Valdemoro Prison.Madrid III-Valdemoro PrisonSpain
| | - Delia González-Tejedor
- Specialist Physician in in Family and Community Medicine. Specialist in Psychiatry at the Madrid III-Valdemoro Prison.Madrid III-Valdemoro PrisonSpain
| | | | - Beatriz Reina-Herraiz
- Nurse and Podiatrist at the Madrid III-Valdemoro Prison.Madrid III-Valdemoro PrisonSpain
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3
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Ohata C, Imamura T. Painful purple toes. Cutis 2016; 98:E8-E10. [PMID: 27814416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Chika Ohata
- Department of Dermatology, Kurume University School of Medicine, Japan
| | - Taichi Imamura
- Department of Dermatology, Kurume University School of Medicine, Japan
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Kobayashi H, Abe M, Murata Y, Maruyama T, Furukawa T, Oikawa O, Okada K. Low-density lipoprotein apheresis for corticosteroid-resistant skin lesions caused by cholesterol crystal embolism: a case report and review of the literature. J Artif Organs 2015; 18:285-9. [PMID: 25821197 DOI: 10.1007/s10047-015-0830-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/08/2015] [Indexed: 11/25/2022]
Abstract
Cholesterol crystal embolism (CCE) is an arterio-arterial embolism originating from the breakdown of atherosclerotic plaques in the aortic wall. The embolism affects the skin and kidney particularly, as well as frequently affects the gastrointestinal tract and other organs. Although there are no clearly effective direct therapies for CCE, corticosteroid therapy and combination therapy with low-density lipoprotein apheresis (LDL-A) followed by corticosteroids were recently reported to be effective for renal manifestations in some cases. However, few cases offer suggestions for the treatment of skin lesions caused by CCE. We report here a case of a 58-year-old man diagnosed with CCE with skin manifestations and kidney dysfunction who achieved complete remission after LDL-A. LDL-A may be a useful treatment for CCE, particularly in cases with skin manifestations.
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Affiliation(s)
- Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kami-chou, Itabashi-ku, Tokyo, 173-8610, Japan
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Lee KG, Loh HL, Tan CS. Spontaneous cholesterol crystal embolism--a rare cause of renal failure. Ann Acad Med Singap 2012; 41:176-177. [PMID: 22635282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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7
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Varis J, Kuusniemi K, Heiro M, Järveläinen H. [Blue toe syndrome--a rare but possible complication of anticoagulant therapy]. Duodecim 2011; 127:1154-1157. [PMID: 21755807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Cholesterol microembolization syndrome (CMS) is a multiorgan ischemic disorder resulting from occlusion of small vessels by cholesterol crystals that are derived from atherosclerotic plaques of major arteries. Flow distribution of cholesterol crystals determines the clinical picture of CMS. Cholesterol crystals distributed to the lower extremities cause a typical "blue toe" appearance. The predisposing factors of CMS include various vascular procedures that scratch the luminal surface of the vascular wall and make the release of cholesterol crystals from the atherosclerotic plaques possible. However, CMS can also occur as a consequence of continuous anticoagulant use. Therefore, patients on anticoagulant therapy complaining even minor toe symptoms should be examined for possible CMS.
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Iba Ba J, Mipinda JB, Makanga R, Bignoumba Ibouili R, Coniquet S, Moussavou Kombila JB, Boguikouma JB. [Purple extremities in black-skinned patients: blue toe syndrome as presenting sign of antiphospholipid antibody syndrome]. Med Trop (Mars) 2010; 70:283-284. [PMID: 20734601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Although acral ischemia can involve several underlying mechanisms, suspicion of lupus warrants testing for antiphospholipid antibodies in patients with blue toe syndrome.
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Affiliation(s)
- J Iba Ba
- Service de Médecine A, Centre Hospitalier, Libreville, Gabon.
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9
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Dinis da Gama A, Matias R, Ministro A. [The blue toe syndrome and its pathogenic significance. A case report]. Rev Port Cir Cardiotorac Vasc 2009; 16:231-236. [PMID: 20526478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A 64-years-old woman complained of fixed cyanosis and rest pain of the 2nd, 3rd and 4th toes of the right foot, after a sudden onset one month previously to the clinical examination. The diagnosis of "blue toe syndrome" was then made. She was in a post-menopause state, with no hormonal substitution therapy, complaining also of obesity, arterial hypertension and hyperlipidemia, under medication but no laboratory control. Blood tests excluded an hypercoagulable state and the ECG revealed no significant abnormalities. Angio-CT scans and conventional angiography disclosed an atherosclerotic lesion at the femoropopliteal level, with an adherent and floating thrombus in the arterial lumen, causing microemboli to the collateral digital arteries. The complex lesion was removed through a local thromboendarterectomy, followed by a Carrel-DeBakey patch graft angioplasty, using autologous saphenous vein. Post operative course was uneventfull, with an immediate recovery of the clinical picture. Double antiplatelet therapy was advised and an extensive investigation of the possible relationship of this event with an occult malignancy was started, with no conclusive results, until now. The patient was placed in a clinical, laboratory and imagiologic surveillance program and the main features of this entity are emphasized and discussed, according to the data published in the literature on the subject.
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Affiliation(s)
- A Dinis da Gama
- Clínica Universitária de Cirurgia Vascular, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte e Hospital da Luz Lisboa
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Liu DG, Liu FJ. [Cholesterol crystal embolism of toe: report of a case]. Zhonghua Bing Li Xue Za Zhi 2007; 36:857-858. [PMID: 18346364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Nijhof IS, Majoie IML, Dijkhorst-Oei LT, Bousema MT. [Blue toe syndrome; a sign of end-arterial occlusion]. Ned Tijdschr Geneeskd 2007; 151:1261-7. [PMID: 17624153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Three patients, two women aged 66 and 43 years, respectively, and a man aged 76 years, presented with sudden, painful, blue areas in the toes with intact peripheral pulsations. One patient had a myeloproliferative syndrome due to essential thrombocytosis, the second patient had thromboangiitis obliterans, and the third patient had a cholesterol embolism, possibly due to the use of oral anticoagulants. After treatment, one patient recovered fully and the other two improved significantly. The blue toe syndrome is the pathophysiological consequence of end-arterial occlusion and frequently the first manifestation of a systemic disorder, such as atheroembolism or vasculitis. Adequate treatment is possible in most cases. Therefore, it is very important to recognise this disorder and its possible causes so as to prevent further episodes of local symptoms and especially systemic complications.
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Affiliation(s)
- I S Nijhof
- Meander Medisch Centrum, Postbus 1502, 3800 BM Amersfoort
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Matsumura T, Matsumoto A, Ohno M, Suzuki S, Ohta M, Suzuki E, Takenaka K, Hirata Y, Fujita T, Nagai R. A Case of Cholesterol Embolism Confirmed by Skin Biopsy and Successfully Treated with Statins and Steroids. Am J Med Sci 2006; 331:280-3. [PMID: 16702800 DOI: 10.1097/00000441-200605000-00010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although cholesterol embolism syndrome was recognized as a clinicopathologic entity more than 50 years ago, it is attracting growing attention recently. It is a multisystemic disorder in which cholesterol crystals released from atherosclerotic plaques obstruct small arterioles, resulting in local ischemia and end-organ damage. There are no established treatments, and with the limited treatment options available, it is important to make the diagnosis as early as possible. We present the case of a 68-year-old man with cholesterol embolism who had a few fluttering atheromas in the aorta, as demonstrated by transesophageal ultrasonography. The diagnosis was confirmed by skin biopsy, and treatment with statins and steroids proved effective, as renal failure progressively improved. This case emphasizes the importance of early diagnosis and shows the possible therapeutic effects of statins and steroids for patients with this syndrome.
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Affiliation(s)
- Takayoshi Matsumura
- Department of Cardiovascular Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Tang J, Cheung PS. A 77-year-old woman with sudden onset of blue discolouration of right third toe. Hong Kong Med J 2006; 12:77-9. [PMID: 16495596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
We report on a 77-year-old woman with a history of peripheral vascular disease who presented with an acute-onset tender blue toe and deteriorating renal function. A clinical diagnosis of blue toe syndrome was made but the patient deteriorated rapidly and died. This case illustrates the rapidly devastating nature and fatality of blue toe syndrome. There is no effective treatment for this condition.
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Affiliation(s)
- J Tang
- Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Hong Kong.
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Yücel AE, Kart-Köseoglu H, Demirhan B, Ozdemir FN. Cholesterol crystal embolization mimicking vasculitis: success with corticosteroid and cyclophosphamide therapy in two cases. Rheumatol Int 2005; 26:454-60. [PMID: 16025335 DOI: 10.1007/s00296-005-0012-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2004] [Revised: 04/16/2005] [Indexed: 01/03/2023]
Abstract
Cholesterol crystal embolization is a potential complication of atherosclerosis. Approximately one-third of the patients who develop this problem have a history of vascular surgery, angiography or angioplasty hours to weeks before onset. The skin and the kidneys are most frequently involved, but any organ can be affected. Livedo reticularis of the lower extremities and acrocyanosis (known as "blue toe syndrome") are the most common cutaneous manifestations. Histological examination is the only way to definitively diagnose cholesterol crystal embolization. Recently, it has been proposed that cholesterol embolization is associated with vasculitis, and some authors have labeled this condition a "vasculitis look-alike." There is still no specific treatment for this problem, even in cases that progress to renal failure. However, a few case reports in the literature have noted successful treatment with corticosteroids and cyclophosphamide in patients with deteriorating renal function. In this article, we describe two cases of severe cholesterol crystal embolization accompanied by renal dysfunction) and blue toe syndrome. Both patients benefited from corticosteroid and cyclophosphamide therapy.
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Affiliation(s)
- A E Yücel
- Division of Rheumatology, Baskent University Faculty of Medicine, 5.sok No:48, Bahcelievler, Ankara, Turkey
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Crownover BK, Jones HM. Swollen, discolored toes. Am Fam Physician 2004; 70:919-20. [PMID: 15368731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
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Abstract
Blue toe syndrome is a manifestation of distal embolization associated with significant pain and risk of tissue loss. The recommended treatment options for this problem include endarterectomy or bypass with exclusion of the source of emboli. Although focal arterial stenosis can be effectively treated with angioplasty,it is unclear whether performing angioplasty in a lesion suspected of causing distal embolization might actually worsen the condition or what long-term effects this would have in preventing future embolization. The purpose of this study was to evaluate the treatment and outcome of a series of patients with unilateral blue toe syndrome treated with percutaneous angioplasty and stenting. During a 5-year period, a total of 8 patients were identified with unilateral blue toe syndrome. Ankle/brachial indices (ABIs) were obtained, followed by arteriography. The study group included 4 men and 4 women with an age range of 35 to 83 years. Their atherosclerotic risk factors included smoking (8), hypertension (5), diabetes mellitus (3), and hypercholesterolemia (1). One patient had a history of illicit drug use. The patients were followed up by repeat clinical examinations and vascular laboratory studies. Arteriography typically demonstrated a focal preocclusive lesion with thrombus at the distal end of the lesion. Angioplasty and stent placement was technically successful in all cases. The ABIs increased following angioplasty (before 0.81 +/- 0.05; after 1.02 +/-.05). The symptoms resolved in all 8 patients over the ensuing month, and there were no recurrences with a mean follow-up of 18.5 months (range 4 to 36 months). There was 1 death at 4 months associated with preexisting colon carcinoma. Unilateral arterial to arterial emboli were found in association with focal preocclusive lesions. Despite the presence of thrombus in some of the lesions, these patients were not acutely worse following angioplasty. There was good initial angiographic success in all cases. There was also hemodynamic improvement as shown by the increased ankle/brachial indices. Although long-term follow-up is not available, these intermediate results suggest that angioplasty and stenting should be considered a reasonable alternative to standard operative approaches for patients with blue to syndrome associated with embolization from a focal stenosis.
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Affiliation(s)
- A Renshaw
- University of Nebraska Medical Center and Methodist Hospital, Omaha, NE 68114, USA
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Kazancioğlu R, Erkoç R, Bozfakioğlu S, Türk S, Gören T, Kayacan SM, Kiliçaslan I, Baykal C, Büyükbabani N, Aysuna N, Ark E. Clinical outcomes of renal cholesterol crystal embolization. J Nephrol 1999; 12:266-9. [PMID: 10493571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Cholesterol crystal embolization is an increasingly recognized disease, presenting with a wide clinical spectrum, usually occurring in elderly men who undergo an angiographic procedure or vascular surgery. We report three patients who developed systemic cholesterol embolic disease and varying degrees of renal failure after angiographic interventions of the coronaries.
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Affiliation(s)
- R Kazancioğlu
- Istanbul Faculty of Medicine, Department of Internal Medicine, Turkey.
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Suárez Fernández R, Herrera M, de Eusebio E, Sánchez Yus E. [Skin biopsy in the diagnosis of systemic pathology caused by cholesterol microemboli]. An Med Interna 1999; 16:321. [PMID: 10422305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Abstract
The signs and symptoms of vasculitis are not specific, and tests for confirming the diagnosis can be misleading. Thus, when considering a diagnosis of vasculitis, physicians need to keep an open mind. With a case vignette, the author illustrates some of the difficulties in diagnosing "vasculitis."
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Affiliation(s)
- K E Sack
- University of California San Francisco 94143-0326, USA
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Affiliation(s)
- S Zaman
- Poole Hospital NHS Trust, Dorset, UK
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Abstract
The blue toe syndrome is characterized by tissue ischemia secondary to cholesterol crystal or atherothrombotic embolization leading to occlusion of small vessels. Embolization occurs typically from an ulcerated atherosclerotic plaque located in the aorto-iliac-femoral arterial system. Clinical presentation can range from a cyanotic toe to a diffuse multiorgan systemic disease that can mimic other systemic illness. Mortality can be higher than 70% depending on the scope of the illness. Embolization can occur spontaneously or from a variety of insults such as invasive vascular procedures, anticoagulation, or thrombolytic therapy. Angiography, duplex ultrasonography, computerized tomographic scanning, and magnetic resonance imaging have been used to image the offending lesions, with angiography considered the "gold standard" despite its inherent risks. Recently, transesophageal echocardiography has been shown to be a helpful tool in imaging the thoracic aorta and delineating in great detail the anatomy of the aortic atheroma. At present, surgery remains the most viable treatment option. However, we look to the future for large randomized trials to help predict embolization and thus the proper medical therapy.
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Affiliation(s)
- R M Applebaum
- New York University School of Medicine, Tisch Hospital, NY 10016, USA
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Abstract
Cyanosis of the digits may have several etiologies ranging from trauma to connective tissue disease; however, the most common cause of the so-called blue toe syndrome is atheroembolic disease or aneurysm and is frequently misdiagnosed on initial presentation. Pedal pulses are often palpable which may misdirect the physician from a diagnosis of vascular pathology. Furthermore, the proximal source of embolic shower may be far from the sight of symptoms. Noninvasive vascular testing, peripheral angiography, abdominal and popliteal ultrasonography, and echocardiography are all techniques that may be beneficial in discovering the origin of emboli. Atheroembolisms and aneurysms can be limb-threatening or life-threatening and hence early diagnosis is imperative.
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Affiliation(s)
- B D Caldwell
- Department of Podiatric Medicine, Ohio College of Podiatric Medicine, Cleveland, USA
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Ishihara T, Ohkubo T, Nakano T, Ohsawa N. [Cholesterol (cholestelin) embolization syndrome--blue toe syndrome]. Ryoikibetsu Shokogun Shirizu 1996:469-72. [PMID: 9047906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- T Ishihara
- First Department of Internal Medicine, Osaka Medical College
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Affiliation(s)
- M F Abdelmalek
- Mayo Graduate School of Medicine, Mayo Clinic Rochester, Minnesota 55905
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