| Sumario: | Hydrophilic polymer embolism (HPE) is a rare complication of endovascular procedures caused by embolization of polymer coatings from vascular devices. We report a 72-year-old man with peripheral artery disease, diabetes, and chronic kidney disease who developed painful, nonhealing lower-extremity ulcers presenting shortly after vascular stenting. Initial biopsies and an extensive infectious and autoimmune workup were nondiagnostic, and the patient failed treatment for presumed pyoderma gangrenosum. Repeat biopsies later revealed amorphous blue material in dermal vessels, highlighted by Alcian blue staining, confirming HPE. Despite treatment with pentoxifylline and wound care, disease progression led to bilateral below-the-knee amputations. This case highlights the diagnostic challenge of HPE, which can present months after endovascular intervention and mimic other ulcerative disorders. Histologic findings are subtle, and early coordination with dermatopathology is key. Clinicians should maintain high suspicion for HPE in patients with unexplained ulcers and vascular procedure history, as early recognition may reduce morbidity. KEY POINTS: A temporal association between endovascular procedures and rapid onset of nonhealing ulcerations should raise suspicion for iatrogenic embolic phenomena. Early recognition of hydrophilic polymer embolism (HPE) is essential to avoid inappropriate treatment and reduce the risk of severe outcomes such as limb loss. Initial misdiagnosis of pyoderma gangrenosum led to prolonged, ineffective immunosuppressive therapy. HPE can mimic neutrophilic dermatoses both clinically and histologically, highlighting the need for repeat biopsy and special stains when ulcers do not respond to standard treatments. The histopathologic hallmark of HPE is amorphous Alcian blue-positive material within dermal vessels.
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