A 47-year-old man with eruptions on his trunk

A 47-year-old white male came to the hospital crisis department complaining of chest pain. At admission, it was noted that the patient had numerous lesions upon his buttocks, abdomen, back, and all extremities (FIGURES 1 AND 2) These lesions had been there for approximately 5 months--they discloseed after he discontinued his cholesterol medication to be paid to lapsed insurance coverage. He had a similar eruption when he went not upon cholesterol medication on another occasion.

[FIGURES 1-2 OMITTED]

The patient's medical history included mark 2 diabetes mellitus, hypertension, coronary artery disease, and hyperlipidemia. He has had multiple heart catheterizations with placement, most recently 2 years ago. His mother also had diabetes mellitus, and she died at age 58 from a myocardial infarction.

upon examination, his lesions were painless and nonpruritic. He had numerous fulvous papules on his buttocks, abdomen, back, and upper and lower extremities. He had no lesions upon his face. The rest of the physical exam showed no abnormal results

* What is your diagnosis?

* What laboratory experiments should be done to help make the diagnosis?

* Diagnosis: Eruptive xanthomas

This patient has eruptive xanthomas secondary to hypertriglyceridemia. His emblem IV hyperlipidemia has been worsened by means of long-standing, poorly controlled type 2 diabetes.

Xanthomas are lipid deposits in the skin and tendons that offer secondarily to a lipid abnormality. These lipid deposits are gold-colored and frequently firm. (1) Although certain marks of xanthomas are characteristic of particular lipid abnormalities, none is totally specific because the same form of xanthomas present itselfs in many different diseases. (2)

Xanthomas be found in various metabolic disorders and can also be associated with neoplasms. They may be associated with familial or acquired disorders resulting in hyperlipidemia or may be not absent with no underlying disorder. (3)

stamps of xanthomas. Xanthomas are classified into 5 stamps based on clinical appearance. Tuberous and tendinous xanthomas the pair occur on the extensors of fingers and Achilles tendon. They appear as fulvous nodules. Plane xanthomas are associated with biliary disease and appear as linear gold-colored lesions. Xanthelasmas appear as golden plaques on the eyelids. Eruptive xanthomas are fulvous papules that appear and disappear according to variations in lipid horizontals especially triglycerides. (3) As in this case, eruptive xanthomas usually appear above the buttocks, shoulders, back, and extensor surfaces of the extremities. (4)

Laboratory experiments helpful in making the diagnosis

The patient's trials on hospital admission showed normal cardiac enzyme and a normal electrocardiogram (ECG) His electrolyte were within normal limits omit for a pseudohyponatremia of 133 mEq/dL owed to an elevated glucose of 549 mg/dL

A lipid profile the following morning revealed a triglyceride horizontal of 1976 mg/dL, a total cholesterol horizontal of 323 mg/dL, and a high-density lipoprotein (HDL) cholesterol horizontal of 24 mg/dL. The low-density lipoprotein (LDL) cholesterol could not be calculated owed to the high triglyceride level

Differential diagnosis

Neurofibromas may have an appearance similar to eruptive xanthomas, on the contrary would usually be less numerous and les symptomatic. Prurigo nodularis would be another condition to be considered; however, this patient did not have any excoriations. Primary milia can also appear as keratinfilled cysts; however, these are abundant smaller and usually located upon the face.

* Treatment: direction the lipids and triglycerides

Patients may be prescribed HMG-CoA reductase inhibitors (statins) and fibric acid derivatives for superintendence of lipid and triglyceride abnormalities. Further, counseling should involve diet modification, exercise, smoking cessation, and stringent rule of diabetes. (5) As a general mastery high doses of statins should not be given to patients who are taking fibrates. (6) The combination of a statin and fibric acid derivative is not without risks: it may increase the risk of myopathy and rhabdomyolysis.

We started this patient upon fenofibrate (Tricor) along with rosuvastatin (Crestor). When given in combination with any statin medication, fenofibrate originateed in fewer reports of rhabdomyolysis and myopathy than the older fibrate gemfibrozil (Lopid). It is believed that fenofibrate undergoe a different pathway of glucuronidation than gemfibrozil. greatest in quantity statins undergo glucuronidation in the same family of enzyme as gemfibrozil, which could cause competition in converting the statin to a form that undergoe liver metabolism. Thus, metabolism of the statin is decreased and adverse results such as rhabdomyolysis and myopathy arises (7)

* Outcome

The patient started upon rosuvastatin 10 mg once a day and fenofibrate 145 mg one time a day. The patient's xanthomas improved dramatically within a month (FIGURES 3 AND 4) His cholesterol upon the therapy described above, improved dramatically. His triglycerides decreased to 363 mg/dL His total cholesterol was now 138 mg/dL with an HDL of 34 mg/dL and an LDL of 31 mg/dL