Faryal Nadeem, MD; Syed Shabbir, MD
November 13, 2017
A 43-year-old male (BMI 38) with diabetes and familial hypertriglyceridemia presented to the emergency department with acute onset abdominal pain. He described a severe, sharp abdominal pain localized to left lower quadrant associated with nausea and vomiting. At home, he was taking metformin, lisinopril, Novolin, and gemfibrozil. However, he had been noncompliant for the last three weeks.
A CT abdomen was concerning for acute pancreatitis, and a lipid panel showed triglyceride levels of >10,000 mg/dL, a total cholesterol of >1000 mg/dL, and an HDL of 20 mg/dL. The patient’s LDL was notably low, and ranged from 30-50 mg/dL.
He was treated urgently with aggressive hydration, IV insulin, and plasmapheresis, with his plasma notable for milky coloration (Figure 1). His triglyceride levels improved to 3246 mg/dL and subsequently to <500 mg/dL after two sessions of plasmapheresis, with associated improvement in his symptoms. He was reinitiated on his oral anti-hyperlipidemic regimen and dietary restriction.
The patient reported a similar condition in his siblings and other family members. This suggested a hereditary disorder such as lipoprotein lipase deficiency. Unfortunately, mutations in the lipoprotein lipase gene were not examined in this patient.
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References
1. Berglund L, Brunzell JD, Goldberg AC, et al. Evaluation and treatment of hypertriglyceridemia: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(9):2969-89.
2. Rubins HB, Robins SJ, Collins D, et al. Diabetes, plasma insulin, and cardiovascular disease: Subgroup analysis from the department of veterans affairs high-density lipoprotein intervention trial (VA-HIT). Arch Intern Med. 2002;162(22):2597-604.
3. Park Y, Lee Y. Images in clinical medicine. lipemia retinalis associated with secondary hyperlipidemia. N Engl J Med. 2007;357(10):e11.
Author Bios:
Faryal Nadeem, MD
Faryal Nadeem is a resident physician in Internal Medicine at Capital Health Regional Medical Center.
Syed Shabbir, MD
Syed Shabbir is a resident physician in Neurology at Montefiore Medical Center.