Hypertriglyceridemia in newly diagnosed d.m
-
Upload
azad-haleem -
Category
Education
-
view
329 -
download
2
Transcript of Hypertriglyceridemia in newly diagnosed d.m
![Page 1: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/1.jpg)
Dr.Azad A Haleem AL.MezoriDCH, FIBMS
Lecturer University Of DuhokColleg of Medicine
Pediatrics Department2016
Hypertriglyceridemia associated with eruptive xanthomas and
lipemia retinalis in newly diagnosed D.M
![Page 2: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/2.jpg)
Case Summary
Five years old girl………• previously healthy presented with a 4-day
history of progressive epigastric abdominal pain, polydepsia, secondary nocturnal enuresis and history of weight loss.
• No fever ?• Past History : IDA ….. • F.H & D.H: nothing significant
![Page 3: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/3.jpg)
Her initial assessment revealed tachypnea with Kussmaul's respiration, tachycardia and moderate dehydration.
CNS; Lethrgic, revealed generalized body weakness
chest; harsh vesicular breathing with good air entry.
Heart: Audible S1 & S2with systolic murmur in the apex.
Abdomen: liver and spleen just palpable.
Case SummaryOn Examination
![Page 4: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/4.jpg)
o The girl was hyperglycemic (plasma glucose level more than 600 mg\dl) and acidotic (pH 7.14, bicarbonate level 3.9 mmol/L), with urinalysis revealing ketonuria and glucosuria.
o CBC & ESR, RFTs, LFTs: within normal limits.
Case Summary Investigations
![Page 5: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/5.jpg)
Diabetic ketoacidosis (DKA)
?Diagnosis…..
![Page 6: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/6.jpg)
Treatment
o After admission, o appropriate fluid resuscitation and o insulin treatment were started. o The patient's diabetic ketoacidosis resolved over 24 hours, o at which point a diabetic diet was introduced along with o subcutaneous insulin therapy (lantus and Novorapid basal
bolus regime).
![Page 7: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/7.jpg)
• On further enquiry… Skin lesions were observed; non-tender yellow papules with creamy-colored centers on face & extensor surfaces of the arms, hands and feet.
Case Summary
![Page 8: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/8.jpg)
• Ophthalmoscopic examination showed creamy white retinal vessels with a faded pinkish white retinal back ground both in the periphery and posterior pole of the retina.
Case Summary
![Page 9: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/9.jpg)
• Laboratory findings showed a grossly lipemic serum with elevated serum levels of triglycerides 2869 mg/dl, cholesterol 498mg/dl, Amylase 45 and HbA1c was 14.8%.
Case Summary
![Page 10: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/10.jpg)
Hypertriglyceridemia associated with eruptive xanthomas and lipemia
retinalis in newly diagnosed diabetes mellitus.
?Diagnosis…..
![Page 11: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/11.jpg)
Treatment • Given the extent of her hyperlipidaemia and
hypergltcemia, the patient put on follow up; • the patient continued on a diabetic diet along with
subcutaneous insulin therapy, and ..• after one month all her investigations were repeated;
serum glucose and lipid profile were normal, and ….• Now the patient has no any skin lesions (eruptive
xanthomas) clinically nor lipemia retinalis on Ophthalmoscopic examination.
![Page 12: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/12.jpg)
Before treatment After medical treatment
Conclusion:This case illustrates a young person with Hypertriglyceridemia associated with eruptive xanthomas and lipemia retinalis in newly diagnosed diabetes mellitus.
![Page 13: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/13.jpg)
Hypertriglyceridemia associated with eruptive xanthomas and lipemia
retinalis in newly diagnosed diabetes mellitus.
Some theory …..
![Page 14: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/14.jpg)
Brief review of lipoprotein metabolism• Lipoproteins, which transport non-water
soluble cholesterol and triglycerides in plasma.• Lipoproteins are generally classified according
to their density as:• Chylomicron, • Very Low Density Lipoprotein (VLDL),• Intermediate Density Lipoprotein(IDL), • Low Density Lipoprotein (LDL) and • High Density Lipoprotein (HDL).
![Page 15: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/15.jpg)
o Chylomicrons: o The formation of chylomicrons takes place in the enterocytes. • Chylomicrons are secreted into the lymphatic circulation before
entering the bloodstream. o In plasma, chylomicrons by the lipoprotein lipase form smaller,
triglyceride-poorer particles known as chylomicron-remnants.
![Page 16: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/16.jpg)
• Chylomicron-remnants are cleared by the liver through:
• LDL B/E receptor or • LRP receptor (LDL-receptor related protein).
![Page 17: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/17.jpg)
• VLDL particles are secreted by the liver.• In plasma, triglycerides of VLDLs are
hydrolyzed by the lipoprotein lipase leads to the formation of IDL particles.
![Page 18: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/18.jpg)
• IDL particles are either:• cleared by the liver through LDL B/E receptor
or • further metabolized by hepatic lipase to form
LDLs.
![Page 19: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/19.jpg)
• LDL is the final product.• LDL is the main cholesterol-bearing lipoprotein
in plasma.• Clearance of LDL is mediated by the LDL B/E
receptor.
30%
70%
![Page 20: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/20.jpg)
• HDLs particles are secreted by the hepatocytes .• Within HDL particles, free cholesterol is esterified by LCAT (Lecithin
Cholesterol AcylTransferase) leading to the formation of HDL3 particles.
• The fusion of 2 HDL3 particles leads to the formation of one larger size HDL2 particle.
• HDL2 lipoproteins are degraded by the hepatic lipase and the endothelial lipase, leading to the formation of HDL remnant particles that are cleared by the liver.
30%
70%
![Page 21: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/21.jpg)
Insulin and lipoprotein metabolism• Insulin plays a central role in the regulation of
lipid metabolism.
![Page 22: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/22.jpg)
1: insulin inhibits hormone-sensitive lipase.
2 : insulin activates LipoProtein Lipase (LPL)
3: insulin inhibits hepatic VLDL production.
4: insulin increases LDL B/E receptor expression.
5:insulin activates LCAT (Lecithin Cholesterol AcylTransferase)
6: insulin activates Hepatic Lipase (HL).
![Page 23: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/23.jpg)
Conclusion
• This case illustrates a young person with Hypertriglyceridemia associated with eruptive xanthomas and lipemia retinalis in newly diagnosed diabetes mellitus.
• Previous proposals to explain this phenomenon include: genetic abnormalities of lipoprotein lipase 1 , or a transient decrease in lipoprotein lipase activity secondary to insulin deficiency 2,3 .
1 - Karagianni C, StabouliS, Roumeliotou K, et al. Severe hypertriglyceridaemiain diabetic ketoacidosis: clinical and genetic study. Diabet Med 2004;21:380–2. 2 - Nyamugunduru G, Roper H. A difficult case: Childhood onset insulin dependent diabetes presenting with severe hyperlipidaemia. BMJ. Jan 4, 1997; 314(7073): 62–65. 3 - Abbate S, Brunzell J. Pathophysiology of hyperlipidemia in diabetes mellitus. Cardiovasc Pharmacol. 1990;16 Suppl 9:S1-7.
![Page 24: Hypertriglyceridemia in newly diagnosed d.m](https://reader036.fdocuments.net/reader036/viewer/2022062503/58ed71a21a28ab6b4b8b46c3/html5/thumbnails/24.jpg)
THANKS FOR YOUR ATTENTION