Eruptive xanthomas in a patient with severe hypertriglyceridemia and type 2 diabetes.

1600 CMAJ, December 10, 2013, 185(18) © 2013 Canadian Medical Association or its licensors A46-year-old man with obesity, hypertension, hyperlipidemia and bipolar disorder presented with a rash (Figure 1) accompanied by ongoing excessive urine production, excessive thirst and blurred vision. The lesions had appeared on his arms 1 month earlier and had spread to his neck, buttocks and legs. He was taking quetiapine and metoprolol. Both of the pat ient’s parents had type 2 diabetes mellitus. A physical examination showed crops of firm yellow–red papules (diameter 1–3 mm) distributed on the patient’s neck, bilateral extremities and buttocks, suggestive of eruptive xanthomas. Lab oratory investigations showed elevated levels of triglycerides (64.2 [normal 0.6–2.8] mmol/L), cho lesterol (18.2 [normal 3.1–5.2] mmol/L), acet y l ated hemoglobin (139.3 [normal 25.6–42.0] mmol/ mol) and glucose (31.2 [normal 3.3–6.1] mmol/ L). Results of kidney and liver function tests were normal, as were the results of tests for thyroid stimulating hormone, triiodothyronin, thyroxin, amylase and lipase. Eruptive xanthomas are characterized by the sudden appearance of grouped, yellow–red pap ules scattered over the trunk, arms, legs and buttocks. The condition is associated with the markedly elevated serum triglyceride levels that occur with hyperlipidemia syndromes (ie., Fredrickson– Levy types I, IV and V) or with diabetes mellitus, hypothyroidism, obesity, pancreatitis, nephrotic syndrome, cholestatic liver disease, dysglobulinemia and as an adverse effect of using certain medications (e.g., estrogens, corticosteroids, systemic retinoid agents). Treatment involves management of the underlying condition, whereby lesions resolve within weeks to months. Patients should also be counseled on lifestyle changes, including weight control, adopting a lowfat diet, exercising and quitting smoking. Our patient’s lesions were likely due to a combination of type V hyperlipoproteinemia (mixed hypertriglyceridemia), undiagnosed type 2 diabetes mellitus and use of antipsychotic agents, although it is difficult to determine the instigating factor. He was admitted to the intensive care unit, and his condition responded well to treatment with insulin, metformin and gemfibrozil. The patient’s quetiapine was stopped, and he was transitioned to topiramate without complications. The patient’s trigly ceride levels improved to 13.8 mmol/L after 8 days of treatment, and his skin lesions im proved after 8 weeks.