SAT-572 Extremely Elevated Plasma Lipoprotein X Level Secondary to Alcoholic Cholestasis

Background Marked elevations of plasma lipoprotein X (Lp-X) levels have been reported in patients with cholestasis due to primary biliary cirrhosis, pancreatic cancer, hepatitis C, and quetiapine. We now report a patient with extreme elevation of plasma Lp-X due to alcohol-induced cholestasis. Case Presentation A 44 year-old African American male presented with painless jaundice and fatigue for one week. He denied nausea, vomiting, diarrhea, change in stool or urine color, or weight loss. He consumes 720-1080 mL of beer (2-3 cans) every night and admitted to heavier alcohol consumption in the past. On physical examination he had scleral icterus and hepatomegaly but no xanthomas or xanthelasmas. His serum total cholesterol was 1,126 mg/dL (normal range, 120-199 mg/dL), triglycerides were 238 mg/dL (50-150 mg/dL), calculated LDL-cholesterol was 1,072 mg/dL (<100 mg/dL), and HDL-cholesterol was 6 mg/dL (>39 mg/dL). His serum AST, 162 IU/L (10-50 IU/L); ALT, 79 IU/L (10-50 IU/L); alkaline phosphatase, 1,058 IU/L (40-129 IU/L); total bilirubin, 18.8 mg/dL (0.2-1.3 mg/dL); direct bilirubin, 13.5 mg/dL (0-0.3 mg/dL); and gamma glutamyl transferase, 4,583 IU/L (8-61 IU/L) were markedly elevated. His blood alcohol level was 34 mg/dL (not detected), sodium 124 mmol/L (135-145 mmol/L), and platelet count was 84,000/µL (150,000-459,000/µL). His TSH 2.89 µIU/mL (0.4-4.5 µIU/mL), UA without proteinuria, HBV immunized, HCV negative, and anti-mitochondrial antibody negative. CT abdomen revealed hepatic steatosis and gallbladder swelling without evidence of obstruction. MRCP showed cirrhosis without primary sclerosing cholangitis. Serum lipoprotein electrophoresis confirmed the presence of Lp-X. On day 3 of hospitalization, his cholestasis improved and his serum total bilirubin 10.0 mg/dL, direct bilirubin 7.4 mg/dL, AST 108 IU/L, ALT 66 IU/L, and alkaline phosphatase 663 IU/L had improved. The patient was advised to abstain from all alcohol consumption. Telephone follow up 2 months later with his wife revealed that he had stopped drinking alcohol and that his jaundice had resolved. Conclusions Although alcohol-induced cholestasis is a well-recognized entity, such presentation with extreme elevations of Lp-X has not been previously reported. In such patients, it is important to establish whether extreme hypercholesterolemia is due to LDL or Lp-X since, as opposed to LDL, Lp-X elevations are not considered to be atherogenic.