The Journal of the Arkansas Medical Society Med Journal March 2019 Final 2 | Page 20

Image 2: yellow-domed papules on the lower lip mucosal and
cutaneous surfaces
tance. 4 Secondary causes of hyperlipidemia may
be a result of more common systemic diseases
including: diabetes, obesity, nephrotic syndromes,
and hypothyroidism. 16 Additionally, medications
that increase lipid levels such tamoxifen, steroids,
and retinoids, as well as intoxicants like alcohol,
can result in hyperlipidemia. 5,6,17
Case Presentation
A 43-year-old white male with a past medical
history of type II diabetes mellitus presented with a
one-month history of reddish-yellow, fleshy, clus-
tered papules on his lower lip, posterior neck, and
posterior trunk (see photos 1-3). A 3mm punch
biopsy of a posterior neck papule was performed.
The histopathological findings were consistent
with eruptive xanthoma evidenced by foamy cell
infiltration of the dermis along with intracytoplas-
mic lipids. Additionally, extracellular lipid material
was present in the dermis. Subsequently, a lipid
panel, Hemoglobin A1c (HbA1c), complete blood
count, and complete metabolic panel were per-
formed. The patient’s HbA1c was 10.3%, sug-
gesting the patient’s diabetes mellitus was un-
controlled. The patient’s cholesterol was within
normal limits; however, he had a triglyceride level
of 11,314 mg/dL. Other laboratory findings were
unremarkable.
Discussion
Our patient presented with florid, fleshy pap-
ules. Although the diagnosis of xanthomas can be
made clinically, we wanted to confirm with a bi-
opsy. Since clinically eruptive xanthomas appear
as fleshy papules, there is an extensive differential
diagnosis. Most commonly, the differential diag-
nosis of eruptive xanthomas includes: sebaceous
hyperplasia, granuloma annulare, xanthoma dis-
semanitum, and nodular basal cell carcinoma.
Image 3: yellow-domed papules, some umbilicated and some
coalescing, on the posterior neck
With the exclusion of verruciform xanthomas,
the identification of a cutaneous xanthoma re-
quires evaluation for concurrent metabolic disor-
ders. 12 Work up and management of the underlin-
ing condition is paramount and can prevent seri-
ous complications of elevated triglycerides such as
coronary disease or pancreatitis. 5,6,10,18 If a patient
is found to have a severe elevation in triglycerides,
it may be pertinent to collect a thorough family his-
tory, not only of cardiovascular disease, but also
of other symptoms of dyslipidemias. Establishing
the presence of an inherited disorder would be
beneficial for not only the patient and their family
members, but also for their health care providers.
Treatment of xanthomas is dependent on their
etiology. Xanthomas related to dyslipidemia usu-
ally resolve with control of blood lipid levels. 19 Le-
sions not attributed to an underlying disease may
be surgically excised. Patients often seek relief of
xanthomas for cosmetic purposes.
We present this case out of interest since it is
unusual for a patient to present with such uncon-
trolled diabetes and triglycerides to a dermatolo-
gist. It is important for all health care providers to
be cognizant that dermatologic changes are often
the presenting sign of internal diseases. It is im-
portant for clinicians at all levels to be aware of
this potential presentation, as early detection and
treatment can improve patient outcomes.
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212 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
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Contact AMS for a complete list of references.
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