SELF ASSESSMENT QUESTIONS A patient with atherosclerosis and livedo reticularis

A 73 year old man was admitted with progressive dyspnoea. His past medical history included peripheral artery disease (intermittent claudication of lower extremities) and ischaemic heart disease (angina pectoris). Two months before renovascular hypertension was diagnosed after he presented severe hypertension and mild renal insuYciency (plasma creatinine concentration 150.3 μmol/l). Renal angiography showed a solitary stenosis of his left renal artery. He had undergone a renal angioplasty two weeks before admission. On examination he had signs consistent with cardiac failure with pulmonary oedema; systolic blood pressure was 180 mm Hg and diastolic 100 mm Hg. A reticulated reddish mottling of the skin was seen on his feet (fig 1). His plasma creatinine concentration was 353.6 μmol/l. A skin biopsy specimen revealed needle-shaped crystals in his small arteries (fig 2). The patient’s condition continued to deteriorate; he was treated with vasodilators, diuretics, and pentoxifilline but developed progressive renal insuYciency and refractory heart failure and died 10 days after admission.