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Home , Hypertriglyceridemia, Xanthoma

[ 60-Second Clinician]

Eruptive Associated with Diabetic Ketoacidosis: Lessons from a Case

By Mosunmola Babade, MS 3, Edward Prodanovic, MD, and Eliot Mostow, MD, MPH

ruptive are lipid yellowish, non-tender, soft dis- macrophage in the superficial dermis. deposits in the skin that result tributed over the neck, shoulders, back, (Figure 2) A diagnosis of E from an increase in plasma elbows, knees and left foot. (Figure 1) and eruptive xanthoma secondary to . Eruptive xanthomas Lipemia retinalis was noted on fun- was made. appear as small, grouped, yellow-tan doscopy. There was no evidence of xan- papules on an erythematous base. The thelasma or tuberous xanthoma. Discussion papules range in size from 1mm to was also present. Eruptive xanthomas are a classic skin 2.5mm in diameter and frequently Laboratory findings included a sign of systemic disease.4 This condi- develop on the buttocks, elbows, back, grossly lipemic serum with markedly tion is strongly associated with hyper- and knees, though they can occur on elevated serum triglycerides 5870mg/dl triglyceridemia and secondary hyper- any cutaneous surface including the (nl values 35-160mg/dl); total choles- lipidemias, particularly in .1 .1,2 Eruptive xanthomas can terol 620mg/dl (nl values <200mg/dl); The lipid pattern in type 1 diabetics is arise in linear array (Koebner phenome- glucose 380mg/dl (nl values 70- largely related to glycemic control. Poor non) at sites of local trauma.3 Lesions 115mg/dl); ketones 80mg (nl value glycemic control is associated with generally develop when plasma triglyc- 0mg); glycosylated hemoglobin A1c hypertriglyceridemia and, in some erides exceed 1500mg/dl and recede 15.9% (nl values 5-7.5%); lipase 2740 patients, high serum low-density- when levels fall.1 The cause (nl values 10-140U/l); and amylase (LDL) and low may be familial as in the hyperlipopro- 1804 (nl values 25-125U/l). Arterial HDL-cholesterol concentrations.5 teinemias or, as in this case, secondary pH on admission was 7.18 (nl to uncontrolled diabetes.1,2 Histolog- values 7.35-7.45), and he was found to ically, these xanthomas typically con- be in . Abdominal tain extracellular lipids and a sparse ultrasound showed hepatic steatosis and lymphocytic infiltrate.3 Pruritus is com- a diffusely enlarged suggestive mon, and the lesions may be tender. of pancreatitis. Punch biopsy of the right shoulder Case Report was performed. Histopathological exam- A 42-year-old morbidly obese caucasian ination of the specimen showed a der- male was admitted in diabetic ketoaci- mal infiltrate composed of numerous, dosis with severe abdominal pain. He large foamy histiocytes surrounded by had a four-week history of - tous, grouped papular lesions, which Table I: Common Etiologies of Eruptive appeared in crops and were most Xanthoma & Hypertriglyceridemia prominent on extensor arms, legs, and Fig. 1. Grouped, yellow papules about 1mm in diameter are noted. This appearance is typical of eruptive xanthomas. Fig. 2. back. He denied pruritus or pain. The Ingesting excess alcohol Collections of foamy histiocytes noted within the superficial dermis. patient had been non-compliant with Glucocorticoids his oral hypoglycemic medications for Hereditary/Hepatic (cirrhosis and obstructive) nine months. He denied alcohol abuse. Thiazides There was no family history of hyper- Retinoids triglyceridemia or diabetes mellitus. Physical examination revealed a mor- Idiopathic bidly obese male with a body mass Glucose (diabetes) index (BMI) of 41 with diffuse 1-2mm Lipoid nephrosis

64 Practical May 2006

[ 60-Second Clinician]

In type 2 diabetes, , relative insulin deficiency, and are associated with hypertriglyc- eridemia.1,2 Hypertriglyceridemia results from both increased substrate availability (glucose and free fatty acids) and decreased lipolysis of very-low-density-lipopro- tein (VLDL) triglyceride. This pattern of lipid abnormali- ties can be detected before the onset of overt hyper- glycemia and is thought to be due to . Reported etiologies for eruptive xanthomas (hypertriglyc- eridemia) include hypothyroidism, ingesting excessive alcohol (alcohol abuse), glucocorticoids, hereditary and hepatic diseases such as obstructive disease and cir- rhosis, thiazides, retinoids, idiopathic, glucose (diabetes mellitus), and lipoid nephrosis. A mnemonic is useful to recall these etiologic conditions (Table 1). Complete regression of the cutaneous lesions correlates with lowering triglyceride levels after dietary restriction, medical management of diabetes, and administration of lipid lowering agents. Refractory xanthomas can be treated with surgical excision or other destructive methods, such CO2, pulsed-dye, or Er:YAG laser surgery, chemical agents such as trichloroacetic acid, and cryosurgery.2 It is important to recognize eruptive xanthomas, confirm the presence of elevated triglycerides, and immediately insti- tute treatments to lower triglycerides in order to prevent pancreatitis and its associated chronic sequelae.

1. Nayak KR, Daly RG. Images in clinical medicine. Eruptive xanthomas associated with hypertriglyceridemia and new-onset diabetes mellitus. N Engl J Med 2004;350(12):1235 2. Massengale WT, Nesbitt LT. Xanthomas. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. Vol 2. London: Mosby, 2003:1448-50 3. Miller DM, Brodell RT. Eruptive xanthomatosis with linear koebnerization. J Am Acad Dermatol.1995;33:834-5 4. Naik NS. Eruptive xanthomas. Dermatol Online J 2001;7(2):11 5. Rao GS, Pai GS. Cutaneous manifestations of diabetes mellitus: a clinical study. Indian J Dermatol Venereal Leprol 1997; 63:232-234. New In Your Practice Manageable, Convenient Laser. If you are looking for an effective, more manageable laser for treating vascular lesions, a new high power laser treatment is available. Wavelight announced the recently FDA approved IDAS 532 Laser for the treatment of superficial vascular lesions including and teleangiec- tasias. The IDAS laser features one handpiece with variable spot size adapters, enabling the physician to easily customize treatment for individual vessel lesions without stopping to change headpieces, allowing for a more efficient treatment, Wavelight says. According to the company, the IDAS 532 is ideal for treatment of hemangiomas, spider nevi, port wine stains, and other pigmented lesions that is a good introduction to laser-based therapies to non-laser patients.

58 Practical Dermatology May 2006