Although the “triglyceride paradox” states that hypertriglyceridemia is less frequent in Blacks and the risk of pancreatitis increases with severe hypertriglyceridemia, we herein report on a case of moderate hypertriglyceridemia revealed by an acute chest syndrome and a milky appearance serum in a 47-year-old type 2 diabetes black patient with prior history of recurrent acute pancreatitis. In addition to insulin therapy and coronary angioplasty, the combination of a statin and a fibrate resulted two months later in a substantial improvement in triglyceride levels and a normal serum appearance.
Dyslipidemia in T2DM is characterized by an atherogenic profile with elevated low- density lipoprotein-cholesterol (LDL-c), elevated triglycerides (TG) and decreased high- density lipoprotein-cholesterol (HDL-c) and increases the risk of both coronary artery disease (CAD) [
IB is a 47 years old black patient with type 2 diabetes under mixed insulin since 1994. In August 2014, due to an acute chest pain on walking that usually relieves 3 to 4 minutes after stopping walking, his general practitioner from Brazzaville, Republic of Congo referred him to the outpatient clinic of the Division of Cardiology/University of Kinshasa Hospital for, Republic of Congo. His past medical history is characterized by a history of recurrent acute pancreatitis (2002 and 2003) and hypertension (2009) successfully controlled with a combination of angiotensin converting enzyme inhibitor (Ramipril 10 mg) and thiazide diuretic (Hydrochlorothiazide 12.5 mg). He was not smoking or consuming alcohol and has no physical activity in leisure time. Physical examination revealed a body mass index (BMI), waist circumference (WC), seated blood pressure (BP), pulse rate of 29 Kg/m2, 98 cm, 142/89 mm Hg and 98 bpm, respectively (
Variable | |
---|---|
Age, years | 47 |
Past medical history: | |
-Diabetes (1994) | |
-Acute pancreatitis (2002, 2009) | |
-Hypertension (2009) | |
BMI, Kg/m2 | 29 |
Waist circumference, cm | 98 |
SBP, mm Hg | 149 |
DBP, mm Hg | 89 |
Pulse rate, bpm | 98 |
FPG, mmol/l | 21 |
Serum creatinine, μmol/l | 159 |
GFR-MDRD, ml/min/1.73 m2 | 52 |
Triiodothyroxin (T3), ng/ml | 0.95 |
Tetraiodothyroxin (T4), nmol/l | 106 |
FSH, IU/l | 0.80 |
Abbreviations: BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; FPG, fasting plasma glucose; GFR, glomerular filtration rate; MDRD, modification of diet in renal disease; Follicle stimulating hormone; IU, international unit.
Variable | Before fibrate | After fibrate |
---|---|---|
Total cholesterol mmol/l | 9.87 | 6.80 |
LDL-c, mmol/l | 5.14 | 3.37 |
HDL-c, mmol/l | 1.00 | 1.26 |
Non HDL-c, mmol/l | 8.86 | 5.29 |
TG, mmol/l | 8.09 | 4.86 |
Abbreviations: LDL-c, low-density lipoprotein-cholesterol; HDL-c, high-density lipoprotein-cholesterol; TG, triglycerides.
mixed dyslipidemia with mainly HTG as a component of MetS was retained. Thiazide diuretic and beta-blocker, drugs known to alter glucose and lipid metabolism, were stopped and replaced by oral low release indapamide (2.5 mg) and an angiotensin converting enzyme inhibitor Ramipril (10 mg), respectively. Since statins do not effectively lower TG levels, a fibrate (Oral Fenofibrate 160 mg once daily) was added to statin. Two months later (November 2014), the patient was feeling better and has no complaints. Venipuncture drawn a red blood sample (
We reported on a 47-year-old patient with type 2 diabetes with prior history of acute pancreatitis presenting with an acute chest pain and very important hypertriglyceridemia with a milky appearance serum.
Lipid profile made of increased levels of both cholesterol and TG observed in the present T2DM diabetes case is a well-known feature of mixed dyslipidemia and does translate underlying insulin resistance state [
A milky appearance of serum in the present case does suggest high levels of chylomicrons as observed in type V hyperlipoproteinemia [
Patient’s past-medical history was characterized by two episodes of acute pancreatitis. Hypertriglyceridemia is a well-established cause of acute pancreatitis, accounting for 1% - 4% to 9% of patients who present with acute pancreatitis [
Acute retrosternal chest pain experienced by the patient could be related to the coexistence of multiple CVD risk factors clustering in metabolic syndrome. However, HTG could be one of the most important factors in the development and progression of the dynamic process of atherosclerosis [
Despite the presence of metabolic syndrome suggestive of underlying insulin resistance, the present case was paradoxically receiving insulin to control his T2DM. In case of severe T2DM-associated HTG and poorly controlled diabetes as in the present, continuous intravenous insulin infusion has been reported to be beneficial in reducing plasma glucose and serum TG [
Improvement in serum appearance and lipid profile was observed in the present case two months after the initiation of lipid lowering therapy with a statin and a fibrate. Although statins have some TG lowering effects at higher doses, ranging from 20% to 28%, they are not effective enough to remove the risk of pancreatitis in patients with severe HTG and should not be used in their own as first line agents [
Beta blocker and thiazide diuretic, drugs known to alter glucose and lipid metabolism, were replaced by an angiotensin converting enzyme inhibitor Ramipril and another diuretic indapamide known to have beneficial or neutral effects on glucose and lipid metabolism. Angiotensin 2 alters insulin secretion and sensitivity through the production of pro-inflammatory cytokines and reactive oxygen species with subsequent oxidative [
A milky serum appearance in the context of acute abdominal pain should guide the doctor to a diagnosis of acute pancreatitis, and to propose the triglyceride assay. We have shown here that the complications of hypertriglyceridemia can be seen in black patients, even at relatively moderate rates of triglycerides.
The authors would like to gratefully thank all the staff of the Division of Cardiology of the University of Kinshasa Hospital for the administrative authorization. They are deeply indebted to the patient who by his consent allows the caregivers to improve their skills in providing care to T2DM patients with dyslipidemia.
LFB wrote the manuscript, KEV collected data and revised the manuscript, MJR revised the manuscript, KFM revised the manuscript.
Lepira, F.B., Kintoki, V.E., Makulo, J.R. and Kintoki, F.M. (2016) Moderate Hypertriglyceridemia Re- vealed by Acute Chest Syndrome, a Milky Appearance Serum and Prior History of Re- current Acute Pancreatitis in a Type 2 Diabetes Black Patient: A Case Report. World Journal of Cardiovascular Diseases, 6, 425- 432. http://dx.doi.org/10.4236/wjcd.2016.611046