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Eruptive Xanthomas: a Warning Sign of Future Hyperlipidemia Complications

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Eruptive Xanthomas: a Warning Sign of Future Hyperlipidemia Complications International Journal of Research in Dermatology Nessel TA et al. Int J Res Dermatol. 2020 Jul;6(4):579-583 http://www.ijord.com DOI: http://dx.doi.org/10.18203/issn.2455-4529.IntJResDermatol20202672 Case Report Eruptive xanthomas: a warning sign of future hyperlipidemia complications Trevor A. Nessel1*, Connor C. Kerndt2, John A. Bills1, Lynn Sikorski3 1Department of Dermatology, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan, USA 2Department of Dermatology, Spectrum Health/Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA 3Department of Dermatology, Beaumont Farmington Hills Hospital, Farmington Hills, Michigan, USA Received: 08 April 2020 Accepted: 07 May 2020 *Correspondence: Trevor A. Nessel, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Eruptive xanthomas are localized lipid deposits in the skin or subcutaneous tissue that are associated with both primary and secondary hyperlipidemia. Typical presentation manifests as small yellow papules on the buttocks or extensor surfaces. Xanthomas can be diagnosed clinically with an extensive history and physical examination, however, can be confirmed via biopsy and histological findings. It is essential to identify the underlying cause of the skin lesions and take appropriate measures to prevent future hyperlipidemia-induced consequences. Here we report a 42-year-old female with eruptive xanthomas on her trunk and extremities. Previous visits to the primary care provider and emergency department resulted in diagnoses of viral exanthems. The consulted dermatologist ordered laboratory tests remarkable for extreme hypertriglyceridemia, hypercholesterolemia, and hyperglycemia. Lifestyle modification in conjunction with cholesterol and triglyceride lowering medications led to the resolution of abnormal laboratory findings and remission of eruptive xanthoma lesions. Keywords: Eruptive xanthoma, Hypertriglyceridemia, Hypercholesterolemia, Hyperglycemia, Hyperlipidemia INTRODUCTION phagocytosed by dermal macrophages, causing xanthoma formation.1 As a result of their lipid composition, Xanthoma is a term that encompasses several variants of eruptive xanthomas’ clinical appearance displays yellow localized lipid deposition into the skin or subcutaneous coloration within papules.6 These papules are generally tissue, presenting as nodules, plaques, or papules.1 small, 1.0-5.0 mm in size, and identified on the buttocks Xanthomas most commonly arise amongst adults and or extensor surfaces such as the elbows and knees.7,8 exhibit an even distribution between genders.2,3 The Eruptive xanthomas specifically arise in the setting of mechanisms in which xanthomas arise are not well excessive hypertriglyceridemia, lipid metabolism understood and vary by subcategorization. Eruptive disorders, or onset of diabetes.8 Eruptive xanthomas xanthoma synthesis holds a strong association with differentiate themselves from variants of xanthomas hyperlipidemia, including both primary causes from histopathologically by excessive extracellular lipid inborn metabolic defects and secondary causes such as deposition accompanied by mixed inflammatory obesity, diabetes, and hypothyroidism.4,5 Current models infiltrate.8 The inflammatory infiltrate generally reveals suggest that in patients with hyperlipidemia, lipoproteins several cell types and can include histiocytes, neutrophils, carrying lipids extravasate from the blood and are and lymphocytes.8 Diagnosis is generally established International Journal of Research in Dermatology | July-August 2020 | Vol 6 | Issue 4 Page 579 Nessel TA et al. Int J Res Dermatol. 2020 Jul;6(4):579-583 presumptively based on clinical appearance and history, levels. A punch biopsy was then performed to confirm but can be histopathologically confirmed with excisional, the diagnosis of eruptive xanthomas and rule out other punch, or shave biopsy. Further workup to identify the masquerading pathologies. Aggressive lipid and underlying cause of hyperlipidemia and begin appropriate triglyceride lowering therapy was initiated with intervention to prevent recurrences is often necessary. gemfibrozil and atorvastatin. Given her recent Here we have a unique case in which a middle-aged discontinuation of diabetic medications, glipizide was female presented with eruptive xanthomas and concurrent added to manage her elevated blood glucose levels. extreme hypertriglyceridemia after the discontinuation of her diabetes medication regimen. The patient was re-evaluated one week later. Punch biopsy exhibited tissue with foam cells, mixed CASE REPORT inflammatory cell infiltrate, and extracellular lipid deposits, confirming the diagnosis of eruptive xanthoma. A 42-year-old Caucasian female presented to the Since her initial visit, the patient had implemented dermatology clinic with a 4-week history of a papular significant lifestyle modifications including smoking eruption on her trunk and extremities which progressively cessation, dietary changes, and weight-loss of 11.0 worsened since its onset. In addition to the skin lesions, pounds in conjunction to strict medication adherence. she also noticed nausea and fatigue. The new skin lesions Serial laboratory testing reflected these interventions with exhibited neither pruritus nor pain. The patient had a past drastic reduction of her triglycerides, cholesterol, and medical history of hypertension and non-insulin blood glucose levels (Table 1). The downtrend of these dependent diabetes mellitus, but recently discontinued values exhibited the effectiveness of her treatment which her diabetes medications. After discontinuation, her daily correlated with the resolution of her eruptive papules medications included oral contraceptives and benazepril. (Figure 1). Her social history was significant for a positive smoking history and abstinence from alcohol. The patient’s primary care provider and local emergency department both recently managed this patient for her new skin changes, and attributed her eruption to a viral exanthem. Physical examination displayed a mildly obese female with multiple scattered, 3-4 mm, yellow papules distributed throughout all four extremities and the posterior trunk (Figure 1). Given the clinical appearance, along with her relevant past medical history, a presumptive diagnosis of eruptive xanthomas was made. Laboratory workup included serial lipid panels and blood Figure 1: Eruptive xanthomas consisting of several glucose levels (Table 1). Significant labs showed small, yellow papules on the (A) posterior trunk and extremely elevated triglycerides, cholesterol, and glucose (B) extensor surface of the proximal left upper extremity. Table 1: Significant lab values from lipid panel and blood glucose testing. Patient value: initial Patient value: Patient value: Variables Normal range visit 1-week post-visit 4 weeks post-visit Triglycerides (mg/dl) 14,150 1,630 356 <250 Cholesterol (mg/dl) 1,840 911 253 <200 HDL (mg/dl) Unable to calculate 52 43 40-60 LDL (mg/dl) Unable to calculate Unable to calculate 139 <100 Glucose (mg/dl) 290 - - 65-110 HDL: high-density lipoprotein, LDL: low-density lipoprotein. DISCUSSION Medicine reconciliation allows for prompt identification of possible offending medications that may have When evaluating for new-onset cutaneous xanthomas, it precipitated this condition. Several medications can is imperative to establish a wide differential to consider directly or indirectly alter lipid metabolism, which varying etiologies of its onset. Development of these influences circulating concentration of these molecules. lesions can manifest from a primary or secondary Specifically, estrogens, androgens, glucocorticoids, etiology. Delineating the source of eruptive xanthomas cyclosporine, tacrolimus, thiazide diuretics, beta generally begins with the most commonly offending blockers, sertraline, protease inhibitors, valproic acid, causes, such as medications or underlying medical isotretinoin, and olanzapine have been shown to increase disease/comorbidities. triglyceride levels.9,10 Discontinuing possible contributing International Journal of Research in Dermatology | July-August 2020 | Vol 6 | Issue 4 Page 580 Nessel TA et al. Int J Res Dermatol. 2020 Jul;6(4):579-583 medications and evaluating for resolution of symptoms Many modifiable risk factors affect triglyceride and can affirm suspicion without excessive workup. cholesterol levels. Dietary, exercise, and smoking habits all demonstrate influence of lipid concentrations in the After medication-induced causes, suspicion for organic blood. Recent studies suggest that aerobic exercise elicits underlying disease must be considered. Evaluating for a positive effect on lowering lipid profiles by increased personal or familial history of lipid, glucose, or thyroid utilization of lipids instead of glycogen.18 Smoking disorders can raise suspicion for these etiologic causes. negatively affects lipid profiles through nicotine-induced Diabetes mellitus is strongly associated with catecholamine secretion. This increases lipolysis and hypertriglyceridemia, and eruptive xanthomas may releases fatty acids into the blood. These fatty acids present as the first manifestation of underlying disease.11 undergo
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