Symptom Finder - Hypertriglyceridemia
HYPERTRIGLYCERIDEMIA
In developing a list of possible causes of hypertriglyceridemia, first consider anatomy, particularly the kidney, liver, and endocrine glands.
The kidney should remind one of the nephrotic syndromes which are associated with elevated triglyceride and cholesterol levels. The liver should remind one of obstructive jaundice. Looking at the endocrine glands, consider the pancreas and immediately diabetes mellitus and insulinomas come to mind. Considering the thyroid gland, hypothyroidism comes to mind. Considering the adrenal gland, Cushing syndrome will not be forgotten. Finally, consider the pituitary gland and acromegaly will be recalled. Other causes of secondary hypertriglyceridemia include drugs such as thiazide diuretics and β-adrenergic blocking agents, exogenous estrogen, and corticosteroids. If the above conditions have been excluded, the clinician must consider the primary hyperlipoproteinemias; the triglycerides are elevated in type I, II-b, III, IV, and V. These may be further differentiated by looking at the chylomicron and cholesterol levels. In type I, there is marked elevation of chylomicrons but the cholesterol is normal. In type II-b, the chylomicrons are normal but the cholesterol is elevated. In types III and V, the chylomicrons and cholesterol are both elevated, whereas in type IV only the triglyceride is increased and the plasma is clear.
Approach to the Diagnosis
Clinical examination may show eruptive xanthomas, tendon xanthomas, and arcus senilis of the cornea in the primary hyperlipoproteinemias. There may be a clear family history also. Laboratory studies that need to be done include a liver profile, thyroid profile, CRP serum protein electrophoresis, apolipoprotein (LpA) and lipoprotein electrophoresis. However, repeat the study after a 14-hour fast to be sure the elevation is real. Free plasma cortisol will help rule out Cushing syndrome, whereas a growth hormone assay will help rule out acromegaly. Overnight refrigeration of plasma will help differentiate the primary hyperlipoproteinemias.
Other Useful Tests
1. CBC and urinalysis (nephrosis)
2. Sedimentation rate (hepatitis)
3. Chemistry profile (liver disease, kidney disease)
4. Exercise tolerance test (coronary arteriosclerosis)
5. Liver biopsy (biliary cirrhosis)
6. Skull x-ray (acromegaly)
7. Endocrinology consult
8. Glucose tolerance test (acromegaly, diabetes, Cushing syndrome)
9. Plasma insulin assay (insulinoma)
10. C-peptide level (insulinoma)
11. Consultation with a metabolic disease specialist
12. Coronary artery calcium scores (atherosclerosis)
In developing a list of possible causes of hypertriglyceridemia, first consider anatomy, particularly the kidney, liver, and endocrine glands.
The kidney should remind one of the nephrotic syndromes which are associated with elevated triglyceride and cholesterol levels. The liver should remind one of obstructive jaundice. Looking at the endocrine glands, consider the pancreas and immediately diabetes mellitus and insulinomas come to mind. Considering the thyroid gland, hypothyroidism comes to mind. Considering the adrenal gland, Cushing syndrome will not be forgotten. Finally, consider the pituitary gland and acromegaly will be recalled. Other causes of secondary hypertriglyceridemia include drugs such as thiazide diuretics and β-adrenergic blocking agents, exogenous estrogen, and corticosteroids. If the above conditions have been excluded, the clinician must consider the primary hyperlipoproteinemias; the triglycerides are elevated in type I, II-b, III, IV, and V. These may be further differentiated by looking at the chylomicron and cholesterol levels. In type I, there is marked elevation of chylomicrons but the cholesterol is normal. In type II-b, the chylomicrons are normal but the cholesterol is elevated. In types III and V, the chylomicrons and cholesterol are both elevated, whereas in type IV only the triglyceride is increased and the plasma is clear.
Approach to the Diagnosis
Clinical examination may show eruptive xanthomas, tendon xanthomas, and arcus senilis of the cornea in the primary hyperlipoproteinemias. There may be a clear family history also. Laboratory studies that need to be done include a liver profile, thyroid profile, CRP serum protein electrophoresis, apolipoprotein (LpA) and lipoprotein electrophoresis. However, repeat the study after a 14-hour fast to be sure the elevation is real. Free plasma cortisol will help rule out Cushing syndrome, whereas a growth hormone assay will help rule out acromegaly. Overnight refrigeration of plasma will help differentiate the primary hyperlipoproteinemias.
Other Useful Tests
1. CBC and urinalysis (nephrosis)
2. Sedimentation rate (hepatitis)
3. Chemistry profile (liver disease, kidney disease)
4. Exercise tolerance test (coronary arteriosclerosis)
5. Liver biopsy (biliary cirrhosis)
6. Skull x-ray (acromegaly)
7. Endocrinology consult
8. Glucose tolerance test (acromegaly, diabetes, Cushing syndrome)
9. Plasma insulin assay (insulinoma)
10. C-peptide level (insulinoma)
11. Consultation with a metabolic disease specialist
12. Coronary artery calcium scores (atherosclerosis)
