Endocrine Abstracts

Case history: A 33 year old gentleman presented with a 4 month history of an evolving rash. This initially appeared on the extensor surfaces of the knees bilaterally and progressed to involve both arms and the trunk. This rash was not associated with fever, pain, pruritis or any other symptoms. These lesions were diffuse erythematous crops of yellow papules visible over the knees, arms and trunk. The patient was initially diagnosed with folliculitis and treated with oral flucloxacillin with no clinical improvement observed. This necessitated the need to find an alternative explanation for this presentation.

Investigations: On admission, the patient was noted to have a blood pressure of 146/102 mmHg and weight of 84 kg. Venous sampling demonstrated a marked hypertriglyceridemia, hypercholesterolaemia and hyperglycaemia. His triglyceride level was 45.4 mmol/l and total cholesterol 14.1 mmol/l. His HbA1c was 106 mmol/mol with random glucose above 11.1 mmol/l. His renal, liver and thyroid function were normal.

Results and treatment: The description of this rash combined with marked hypertriglyceridemia was suggestive of eruptive xanthomas. These are benign skin lesions presenting as sudden eruptions of grouped, red-yellow papules over the arms, legs and trunk.¹ These lesions can be painful and pruritic, or asymptomatic as in our case. Effective treatment of these lesions requires management of the underlying systemic condition or primary hyperlipidaemia, whereby the lesions typically resolve within weeks to months¹. In our case, eruptive xanthomas were the only symptom of undiagnosed diabetes mellitus and clinically improved three months after diet, lipid and glycaemic control.

Conclusions and points for discussion: This case highlights the importance of first recognising eruptive xanthomas as a cutaneous manifestation of hypertriglyceridemia. This needs to be followed by a work up for the aetiology of hypertriglyceridemia. Whilst hypertriglyceridemia can be attributed to primary hyperlipidaemia, it can alternatively be linked to metabolic diseases such as diabetes mellitus, hypothyroidism, nephrotic syndrome or be drug induced². Finally, whatever is the determined underlying aetiology needs to be treated. In our case, eruptive xanthomas acted as the sole presentation of diabetes mellitus. Identifying the aetiology allowed for management of the underlying condition, whereby the lesions resolved within months.² Such prompt recognition and treatment is essential to prevent potentially life-threatening complications such as acute pancreatitis and coronary artery disease. To conclude, this case emphasises the need to recognise eruptive xanthomas, identify the aetiology of hypertriglyceridemia and treat the underlying cause.