HTML clipboard

INSTRUCTION

Examine this patient's skin.This uncontrolled diabetic has developed a profuse eruption; what are these lesions?

SALIENT FEATURES

History

• Duration and treatment of diabetes.

• History of hyperlipidaemia.

• Rash - duration, onset and evolution and associated symptoms such as itching.

Examination

Multiple, itchy, red-yellow vesicles or nodules which are seen over extensor surfaces,i.e. buttocks, back, knees and elbows.

Proceed as follows:

Tell the examiner that you would like to:

· Examine the fundus for lipaemia retinalis.

· Check the urine for sugar.

· Do a lipid profile (remember that eruptive xanthomata signifyhyper-triglyceridaemia).

DIAGNOSIS

This patient has eruptive xanthomata (lesion) due to hypertriglyceridaemia (aetiology).

ADVANCED-LEVEL QUESTIONS

In which conditions are eruptive xanthomata seen?

• Type IV hyperlipidaemia.

- Familial hypertriglyceridaemia.

- Lipoprotein lipase deficiency.

-Apolipoprotein CII deficiency.

• Type I hyperlipidaemia - chylomicronaemia.

• Type V hyperlipidaemia - increased levels of triglycerides and chylomicrons.

Mention some other causes of hypertriglyceridaemia.

· Primary hypertriglyceridaemia (usually greater than 500 mg/dl): familialhyper-triglyceridaemia, familial combined hyperlipidaemia.

· Secondary hypertriglyceridaemia: diet, obesity, excess alcohol intake, diabetesmellitus, hypothyroidism, uraemia, dysproteinaemias, drugs (beta-blockers, oralcontraceptives and oestrogens, retinoids ).

What is the relationship between hypertriglyceridaemia and coronary artery disease?

The relationship of hypertriglyceridaemia with coronary artery disease is less clear thanthat with hypercholesterolaemia, but is said to increase risk when levels are greater than500 mg/dl, when other risk factors are present or in familial combined hyperlipidaemia.Of what are patients particularly at risk when serum levels of triglycerides are markedlyraised (> 1000 mg/dl)?They are more susceptible to acute pancreatitis and hyperchylomicronaemia.

How would you manage a patient with raised levels of serum triglycerides ?

• Diet: restrict dietary fat, decrease intake of alcohol and simple sugars.

• Weight loss if the patient is overweight.

• Exercise.

• Discontinuation of drugs, e.g. beta-blockers.

• Control secondary causes.

• Niacin or gemfibrozil may be used for elevated triglycerides (>200 mg/dl)regard-less of LDL or HDL cholesterol.