SAT-084 Extremely Severe Asymptomatic Hypertriglyceridemia: A Rare Case Report

Introduction Hypertriglyceridemia (HTG) is a common form of dyslipidemia. It has been shown to increase the risk for acute pancreatitis and cardiovascular disease. The risk of pancreatitis increases when TG levels exceed 1000-2000 mg/dL. Based on literature review, this patient has perhaps the highest recorded TG count without evidence of pancreatitis(1). Case Description A 49-year-old Hispanic female with history of hypertension and asthma presented with chest tightness. Medications included Albuterol inhalers, Losartan, Montelukast, Verapamil, and intermittent Prednisone tapers for asthma exacerbations. She denied alcohol/drug use and quit smoking 13 years ago. Vitals were stable on admission. BMI was 27.7. Chest wall was tender to palpation which was ruled to be musculoskeletal. The remainder of the examination including skin was normal. Initial centrifuged blood on gross examination was heavily lipemic. Lipid panel revealed serum triglyceride of >10,000 mg/dL, serum cholesterol of 1,029 mg/dL, LDL of 33 mg/dL, and HDL of 22 mg/dl. Serum lipase, blood glucose, TSH, and HbA1c were all within normal limits. Urine protein-creatinine ratio was normal. Cardiovascular work-up was negative. IV insulin drip was initiated with IV fluids containing dextrose along with Heparin subcutaneously. These are potent activators of lipoprotein lipase(2,3). A lipid panel from 2016 revealed serum triglycerides of 212 mg/dL and serum cholesterol of 182 mg/dL. On day 9, serum TG levels came down to 825 mg/dL and serum cholesterol was noted to be 360 mg/dL. She was discharged on Rosuvastatin, Fenofibrate and prescription omega-3 fatty acids. Labs one month after discharge revealed serum TG levels of 142 mg/dL and serum cholesterol of 117 mg/dL. The cause of HTG was believed to be repeated Prednisone courses precipitating an underlying genetic HTG disorder. The patient did not follow up for further genetic testing. Conclusion Hypertriglyceridemia is frequently encountered in clinical practice. In cases of severely elevated TG levels (above 1000-2000 mg/dL), rapid lowering to levels < 500-1000 mg/dL must be achieved with aggressive therapy (IV insulin drip and heparin) to prevent the development of acute pancreatitis. References 1. Vangara, S. S., Klingbeil, K. D., Fertig, R. M., & Radick, J. L. (2018). Severe hypertriglyceridemia presenting as eruptive xanthomatosis. Journal of Family Medicine and Primary Care, 7(1), 267-270. http://doi.org/10.4103/jfmpc.jfmpc_270_17 2. Berger Z, Quera R, Poniachik J, Oksenberg D, Guerrero J. heparin and/or insulin treatment of acute pancreatitis caused by hypertriglyceridemia. Rev Med Chil, 2001;129:1373-8. 3. Jabbar M, Zuhri-yafi M, Larrea J. Insulin therapy for a non-diabetic patient with severe hypertriglyceridemia. J Am Coll Nutr, 1998;17: 458-61.