Case Study of Hypertriglyceridemia from COVID-19 Pfizer-BioNTech Vaccination in a Patient with Familial Hypercholesteremia

LEAD AUTHOR'S FINANCIAL DISCLOSURES: Nothing to disclose. STUDY FUNDING: None. BACKGROUND/SYNOPSIS: Familial hypercholesterolemia (FH) is an autosomal codominant genetic disorder with very high levels of low-density lipoprotein cholesterol (LDL-C) due to defective hepatic uptake via LDL receptors. Little data are available about the impacts of a Coronavirus Disease 2019 (COVID-19) Pfizer-BioNTech vaccine on serum lipids in patients with FH. OBJECTIVE/PURPOSE: To evaluate a FH patient presenting with severe hypertriglyceridemia after receiving his COVID-19 Pfizer-BioNTech vaccination. METHODS: A history, physical examination, lipoprotein testing, and standard clinical chemistry laboratory testing were performed. Dextran sulfate cellulose LDL apheresis was performed with the Kaneka Medical America LLC Liposorber LA-15 system. RESULTS: A 60-year-old man has been treated for years with weekly or biweekly LDL apheresis treatments for FH, which was diagnosed >10 years ago using a Dutch Lipid Clinic Network score of 11. He has a history of hypertension, hypothyroidism, ischemic cardiomyopathy, heart failure with reduced ejection fraction, 5 myocardial infarctions (MI), status post coronary artery bypass graft, and 20 coronary artery stents. Medications include rosuvastatin 40 mg/d, ezetimibe 10 mg/d, fenofibrate 145 mg/d, icosapent ethyl 2 grams twice daily, alirocumab 150 mg biweekly, and levothyroxine 200 mcg/d. Prior to each apheresis treatment, he receives hydrocortisone 50 mg intravenously due to prior intolerance. He has maintained a Mediterranean diet and regularly exercises. Family history includes his father, paternal aunt, and paternal grandfather who all had MIs at or before the age of 50. Physical exam has been nonrevealing. He received his Pfizer-BioNTech vaccination doses on 3/10/21 and 3/31/2021. His lipid panel on 4/1/2021 revealed in mg/dL: triglyceride (TG) of 1308; total cholesterol (TC) of 285; direct LDL-C of 102; high-density lipoprotein cholesterol (HDL-C) of 35 (Table 1). LDL apheresis was attempted on 4/1/21, but failed, as the apparatus had very poor flow due to his very elevated triglycerides and cloudy blood (confirmed by Kaneka). He received apheresis 7 days later without complications with his pre-treatment lipid panel revealing in mg/dL: TG of 196; TC of 188; LDL-C of 106; HDL-C of 43. Prior to this, TG levels for the past 8 years averaged 277 mg/dL and 114 mg/dL pre- and post-apheresis, respectively. CONCLUSIONS: A potential increase in TG due to COVID-19 vaccination occurred in a patient with FH and serious atherosclerosis, which prevented a potentially life-saving treatment. This underscores the need to address any rare complications from novel COVID-19 treatments, minimize ASCVD risk, and determine if this is a common side effect of COVID-19 vaccination.