Endocrine Abstracts

We present a case of a 44-year-old chef, presenting with a fortnight’s history of a pruritic rash over his trunk and axillae. He was diagnosed to have hypertension, which was treated by lifestyle interventions. His diet was poor, and he drank 40 units of alcohol per week. His parents had hypercholesterolemia, but there was no history of premature coronary artery disease. On examination, his BMI was 31.62 kg/m², and he had eruptive xanthomata on his chest, abdomen and axillae. His serum was lipaemic, and his triglyceride levels were 112.99 mmol/l, with total cholesterol of 27.3 mmol/l and a low HDL of 0.9 mmol/l. He had normal renal, hepatic and thyroid functions, and had no biochemical evidence of pancreatitis. His random blood glucose obtained at the time of diagnosis was 10.2 mmol/l, and a repeat fasting glucose was 9.2 mmol/l.

The most likely clinical diagnosis was dysbetalipoproteinemia (type III). In order to minimise his significant pancreatitis risk, he was commenced on an intravenous insulin infusion and Atorvastatin. The therapy had a dramatic effect on his lipid profile, within 24 h triglycerides were 35 mmol/l. He was subsequently commenced on Bezafibrate. A week after discharge, his triglycerides were 9.9 mmol/l and cholesterol 9.6 mmol/l.

Often in patients with dysbetalipoproteinemia, an additional factor that increases lipoprotein production or impairs lipoprotein removal is typically required for full clinical expression, such as diabetes mellitus, hypothyroidism, obesity, or gout. The risk of developing pancreatitis is 1.3–3.8% over a triglyceride level of 11.0 mmol/l and needs urgent therapy. Statins and fibrates take many days to have full therapeutic effect. Insulin activates hormone sensitive lipase, and therefore reduces triglyceride levels by hydrolysing it to lipoproteins which are subsequently stored in the adipose tissue or oxidised. Insulin is a therapeutic option for the emergency treatment of extreme hypertriglyceridaemia.