Eruptive xanthoma: A case of extreme hypertriglyceridemia

Clinical and histopathological features of eruptive xanthoma. Photo courtesy Higher Education Press

This case report, published in Skin, reinforces that the skin can be the first visible sign of a life-threatening metabolic disorder.

The authors from China report that a 30-year-old man arrived at the hospital with a three-day eruption of small, non-pruritic papules. The patient, who had a three-year history of type 2 diabetes and had taken metformin irregularly, reported more than a week of polyuria and polydipsia, along with heavy alcohol intake exceeding 200 grams per day in the preceding week. On examination, erythematous-to-yellowish papules, several millimetres to 1 cm in diameter, were scattered over his trunk and extremities, predominantly on extensor surfaces. Dermoscopy showed a central yellowish structureless area surrounded by an erythematous brown halo.

Laboratory testing revealed the gravity of the underlying disease: fasting plasma glucose of 28.00 mmol/L, HbA1c of 13.9%, total cholesterol of 19.03 mmol/L, and triglycerides of 77.10 mmol/L. A punch biopsy showed dermal aggregates of histiocytes, foam cell formation, and cholesterol cleft deposition, confirming eruptive xanthoma. In the case report, the authors note that "histopathology remains the diagnostic gold standard when clinical features are equivocal."

The patient was managed with a continuous intravenous infusion of low-dose regular insulin, prophylactic subcutaneous unfractionated heparin to prevent venous thromboembolism, atorvastatin 20 mg daily, fenofibrate 200 mg once daily, and a strict low-fat diet. On day 7, insulin was transitioned to oral metformin 850 mg twice daily plus sitagliptin 100 mg once daily.

At discharge, his fasting glucose had fallen to 5.70 mmol/L and triglycerides to 9.77 mmol/L. The cutaneous lesions began to involute within three weeks, and near-complete resolution was documented at three-month follow-up, by which time triglycerides had reached 2.40 mmol/L and HbA1c 7.1%.

As the authors report, “timely management of the underlying metabolic disorder not only resolves skin lesions but also reduces the risk of acute pancreatitis and cardiovascular events.” They caution that in patients without hypertriglyceridemia, similar symptoms indicate that a paraneoplastic syndrome should be considered.