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Subcutaneous cholesterol crystal deposition in the left index finger.

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LETTERS
1752
dysfunction in rheumatoid arthritis. Arthritis Rheum 33:95-101,
1990
5. Walker SM,McCurdy DK, Shaham B, Brik R, Wietting H, Arora
Y,Lehman TJA, Hanson V, Bernstein B: High prevalence of IgA
rheumatoid factor in severe polyarticular-onset juvenile rheumatoid arthritis, but not in systemic-onset or pauciarticular-onset
disease. Arthritis Rheum 33: 199-204, 1990
6. Ryan BF, Joiner BL, Ryan TA Jr: Minitab, Student Handbook.
Second edition. Boston, Duxbury Press, 1985
Subcutaneous cholesterol crystal deposition in the left
index finger
To the Editor:
Subcutaneous cholesterol crystal deposits are rare,
and to our knowledge, only 2 cases have been reported
recently (1,2). Those deposits appeared to be tophi and were
located on the ankle and the forefoot. In this report, we
present a case of an unusual subcutaneous cholesterol crystal deposit in a finger.
The patient, a 33-year-old man, lacerated his left
index finger with a bill hook (used for pruning) in early 1988,
and the wound subsequently required stitches. Several
months later, he developed localized progressive swelling in
the injured area. In January 1989, the results nf general and
articular examinations were normal, except for the presence
of a firm, slightly tender swelling, 1 cm in diameter, over the
radial aspect of the middle phalanx of his left index finger.
Laboratory test findings included normal levels of
serum cholesterol (4.7 mmoles/liter), high-density lipoprotein cholesterol (1.5 mmoledliter), and triglycerides (0.5
mmoles/liter). A few drops of white, creamy fluid were
aspirated from the mass. Cultures of this fluid yielded no
bacteria, but examination by polarized light microscopy
revealed numerous flat, highly birefringent, rectangular,
platelike cholesterol crystals with notched comers; there
were no urate or pyrophosphate crystals. A radiograph of
the patient’s left index finger showed no local calcifications
o r underlying bony changes.
Recurrence of the mass necessitated its excision in
May 1989. Histologic examination revealed an epidermal
inclusion cyst, with a locally disrupted stratified squamous
epithelium and rupture of keratinized scales in the adjacent
dermis. The rupture was surrounded by a phagocytic giantcell reaction. No cholesterol crystal clefts or hemosiderin
deposits were seen. After excision of the mass, there was no
scamng, infection, or recurrence.
This patient’s clinical presentation and the results of
polarized light microscopy of the aspirated fluid are similar
to findings reported by Fam et a1 (1,2). Nevertheless, our
case is different in that the mass recurred despite fluid
aspiration and, more notably, the histologic profile was
different.
The finding of cholesterol deposits in scarred connective tissue, as reported by Fam et a1 ( l ) , especially when
associated with hemosiderin deposits, has previously been
related to organizing hemorrhages in various bone diseases,
e.g., cholesterol granulomas of the ear (3) and calcaneal
bone cysts (4). Hemorrhage (2) or degenerative release of
cell membrane cholesterol (1) by repeated microtrauma are
logical hypotheses for the pathogenesis of cholesterol crystal
deposition. However, if the trauma hypothesis is correct,
one may ask why cholesterol crystals are not observed more
frequently. The rarity of their Occurrence indicates to us that
a combination of mechanical and/or vascular factors is
necessary for their formation.
Although a primary subcutaneous cholesterol crystal
tophus followed by a puncture-related epidermal inclusion
cyst cannot be completely excluded in this case, we believe
that the observed cholesterol crystals did not arise from a
primary tophus, but from the ruptured cyst, even though we
could not confirm crystal formation histologically at the time
of the patient’s initial presentation. Caution should therefore be
used in the diagnosis of subcutaneous cholesterol crystal
deposition when only an examination of aspirated fluid has
been done.
Daniel Van Linthoudt, MD
Jean-Louis Giovannoni, MD
Henri Ott, MD
Community Hospital
La Cham-de-Fonds, Switzerland
1. Fam AG, Sugai M, Gertner E, Lewis A: Cholesterol “tophus.”
Arthritis Rheum 26: 1525-1528, 1983
2 . Fam AG: Subcutaneous cholesterol crystal deposition and to-
phus formation (letter). Arthritis Rheum 32:1190-1191, 1989
3. Friedman I: Epidermoid cholesteatoma and cholesterol granuloma: experimental and human. Ann Otol Rhino1 Laryngol 68:
57-79, 1959
4. Van Linthoudt D, Lagier R: Calcaneal cysts: a radiological and
anatomico-pathological study. Acta Orthop Scand 49310-316,
1978
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crystals, finger, cholesterol, deposition, index, left, subcutaneous
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