A 37-Year-Old Man With Chest Pain and Elbow/Eyelid Papules

Rajdeep Chana, DO; Saurabh Sharma, MD

Disclosures

June 25, 2021

Physical Examination and Workup

The patient's blood pressure is 127/86 mm Hg, his heart rate is 70 beats/min, and his respiration rate is 16 breaths/min. His oxygen saturation level is 99% on room air, and his temperature 98.4°F (36.9°C). The cardiac examination reveals a regular heart rate, with no murmurs. The lungs are clear to auscultation. The abdomen is not tender to palpation, and no organomegaly is detected. The ocular examination reveals a milky appearance of the retinal arteries.

A yellowish papule is noted on the upper eyelid near the inner canthus. A similar papule is shown below in a different patient (Figure 1).

Figure 1.

Multiple yellowish papules are also noted on the patient's elbows during the skin examination. Figure 2 shows similar lesions in a different patient. The remainder of the physical examination findings are unremarkable.

Figure 2.

A biopsy specimen from one of the skin lesions is examined under a microscope. The histopathologic findings resemble those seen below (Figure 3).

Figure 3.

The patient's hemoglobin A1c level is 9.8% (reference range, <5.8%). A nonfasting lipid profile reveals the following values:

  • Total cholesterol level: 417 mg/dL (reference range, <200 mg/dL)

  • High-density lipoprotein cholesterol level: 20 mg/dL (reference range, ≥60 mg/dL)

  • Low-density lipoprotein cholesterol level: 130 mg/dL (reference range, <100 mg/dL)

  • Triglyceride level: 5077 mg/dL (reference range, <150 mg/dL).

The patient's high-sensitivity troponin T level is elevated at 421 ng/L (reference range, <22 ng/L). An ECG shows biphasic T-wave inversions in the anterior leads. He is taken to the cardiac catheterization laboratory and is found to have a 95% occluded mid-left anterior descending artery, which is successfully treated with a drug-eluting stent.

On discharge, the patient's dosages of insulin and atorvastatin are increased. He is later seen in the cardiology clinic for follow-up. Further blood testing reveals elevated chylomicron levels, normal beta-lipoprotein levels, decreased alpha-lipoprotein levels, and markedly increased very low-density lipoprotein (VLDL) levels.

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