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Home , Dyslipidemia, Hypertriglyceridemia, Xanthoma, Xanthoma disseminatum

THE CLINICAL PICTURE MAHMOUD ABDELGHANY, MD SAMUEL MASSOUD, MD Department of Medicine, Conemaugh Memorial Chairman, Department of Medicine, Medical Center, Johnstown, PA Conemaugh Memorial Medical Center, Johnstown, PA

Eruptive

FIGURE 1. Small, reddish-yellow over the extensor surface of the right forearm and both knees at the time of presentation.

n obese 50-year-old man with , • Albumin 4 g/dL (3.5–5.0) A , recently diagnosed , and • Creatinine 1 mg/dL (0.70–1.40) a history of grand mal seizures presented to the emer- • Glomerular fi ltration rate 79 mL/min/1.73 m2 (> 60) gency room complaining of skin for 1 week. He • Urinalysis showed no proteinuria. denied having fever, chills, myalgia, abdominal pain, Histologic analysis of a lesion-biopsy specimen visual changes, recent changes in medications, or con- showed dermal foamy macrophages and loose , tact with anyone with similar symptoms. which confi rmed the suspicion of eruptive xanthoma. He was a smoker, with a history of 20 pack-years; The patient was started on strict glycemic and he denied abusing alcohol and taking illicit drugs. control. Metformin and doses were increased He had no family history of diabetes, peripheral and was added. Three months later, labora- vascular disease, or . His medi- tory results showed total 128 mg/dL, tri- cations included lisinopril, , , met- glycerides 164 mg/dL, fasting glucose 88 mg/dL, formin, and phenytoin. and hemoglobin A1c 5.5%. This was accompanied by On physical examination, the lesions were small, marked improvement of the skin lesions (FIGURE 2). reddish-yellow, nonpruritic tender papules covering the extensor surfaces of the knees, the forearms, the ■ CAUSES AND DIFFERENTIAL DIAGNOSIS abdomen, and the back (FIGURE 1). Laboratory test re- Eruptive xanthoma is a cutaneous disease most com- sults: monly arising over the extensor surfaces of the ex- • Total cholesterol 1,045 mg/dL (reference range 100–199) tremities and on the buttocks and shoulders, and it • 7,855 mg/dL (30–149) can be caused by high levels of serum triglycerides • Thyroid-stimulating hormone 0.52 mIU/L (0.4–5.5) and uncontrolled diabetes mellitus.1 Hypothyroid- • Fasting blood glucose 441 mg/dL (65–100) ism, end-stage renal disease, and • Hemoglobin A1c 12.6% (4.0–6.0) can cause secondary ,2 which can • Total protein 7.2 g/dL (6.0–8.4) cause eruptive xanthoma in severe cases. Patients with doi:10.3949/ccjm.82a.14081 eruptive xanthoma may also have ophthalmologic and

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 • NUMBER 4 APRIL 2015 209

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FIGURE 2. Resolution of the lesions on the right forearm and the knees after several months of treatment.

gastrointestinal involvement, such as lipemia deposits, and the deposition of hyaluronic acid retinalis (salmon-colored retina with creamy- on the edges.5 con- white retinal vessels), abdominal pain, and sists of numerous, small, red-brown papules .3 that are evenly spread on the face, skin-folds, Other types of xanthoma associated with trunk, and proximal extremities.6 Juvenile include tuberous, tendinous, xanthogranuloma occurs mostly in children and plane xanthoma. Tuberous xanthoma is a and is characterized by discrete orange-yel- fi rm, painless, deeper, red-yellow, larger nodu- low nodules, which commonly appear on the 4 lar lesion, and the size may vary. Tendinous scalp, face, and upper trunk. It is in most cases xanthoma is a slowly enlarging subcutaneous a solitary lesion, but multiple lesions may oc- nodule typically located near tendons or liga- cur.7 Lesions of generalized eruptive histiocy- ments in the hands, feet, and the Achilles ten- toma are fi rm, erythematous or brownish pap- Eruptive don. Plane xanthoma is a fl at or patch ules that appear in successive crops over the xanthoma that can occur anywhere on the body. face, trunk, and proximal surfaces of the limbs. The differential diagnosis includes dissem- most commonly inated , non-Langerhans ■ TREATMENT arises over cell (xanthoma disseminatum, micronodular form of juvenile xanthogranu- Treatment of eruptive xanthoma involves di- extensor loma), and generalized eruptive histiocytoma. etary restriction, exercise, and drug therapy to surfaces of Eruptive xanthoma is differentiated from dis- control the hyperlipidemia and the diabetes.2 the extremities, seminated granuloma annulare by the abun- Early recognition and proper control of hyper- dance of perivascular histiocytes and xan- triglyceridemia can prevent sequelae such as and on the thomized histiocytes, the presence of lipid acute .3 ■ buttocks ■ REFERENCES and shoulders 1. Durrington P. Dyslipidaemia. Lancet 2003; 362:717–731. granuloma annulare. J Cutan Pathol 1986; 13:207–215. 2. Brunzell JD. Clinical practice. Hypertriglyceridemia. N Engl J 6. Rupec RA, Schaller M. Xanthoma disseminatum. Int J Der- Med 2007; 357:1009–1017. matol 2002; 41:911–913. 3. Leaf DA. Chylomicronemia and the chylomicronemia 7. Ferrari F, Masurel A, Olivier-Faivre L, Vabres P. Juvenile syndrome: a practical approach to management. Am J Med xanthogranuloma and anemicus in the diagnosis of 2008; 121:10–12. neurofi bromatosis type 1. JAMA Dermatol 2014; 150:42–46. 4. Siddi GM, Pes GM, Errigo A, Corraduzza G, Ena P. Multiple tuberous xanthomas as the fi rst manifestation of autoso- ADDRESS: Mahmoud Abdelghany, MD, Department of Medi- mal recessive . J Eur Acad Dermatol cine, Conemaugh Memorial Medical Center, 1086 Franklin Venereol 2006; 20:1376–1378. Street, E3 Building, Johnstown, PA 15905; 5. Cooper PH. Eruptive xanthoma: a microscopic simulant of e-mail: [email protected]

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