Palmar xanthomata

Published on 05/05/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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175 Palmar xanthomata

Instruction

Examine this patient’s hands.

Salient features

History

• Family history of hyperlipidaemia and coronary artery disease.

Examination

• Yellowish-orange discolorations over the palmar and digital creases (Fig. 175.1 and see Fig. 173.1E)

• Look for the following signs:

• Xanthelasmata around the eyes (Fig. 170.1)
• Tuboeruptive xanthomata around the elbows and knees (Fig. 173.1F)
• Signs of primary biliary cirrhosis (p. 434)

• Tell the examiner that this patient probably has a type III hyperlipidaemia.

image

Fig. 175.1 Striate palmar xanthomata.

(With permission from Durrington 2003.)

Note: A more generalized form may be associated with monoclonal gammopathy of myeloma or lymphoma.

Remember: Xanthomas are usually not present in mild-to-moderate hypertriglyceridaemia; when present, they do not help to distinguish the various hypertriglyceridaemic disorders

Advanced-level questions

How would you classify hyperlipidaemia?

Fredrickson classification, depending on laboratory findings (see Fig. 173.1 for clinical correlates):

• Type I: raised levels of chylomicrons and triglycerides, normal cholesterol concentration (pancreatitis, eruptive xanthomata and lipaemia retinalis)

• Type IIa: raised LDL and cholesterol levels, normal concentration of triglycerides (premature coronary artery disease, tendon xanthomata and arcus corneae)

• Type IIb: raised levels of LDL, VLDL, cholesterol and triglycerides (premature coronary artery disease)

• Type III: raised β-VLDL (cholesterol-rich) remnants, cholesterol and triglycerides (premature coronary artery disease, peripheral vascular disease, palmar and tuberous xanthomata)

• Type IV: raised VLDL and triglycerides, normal cholesterol (premature coronary artery disease: in some forms, risk of developing chylomicronaemia syndrome)

• Type V: raised chylomicrons, VLDL, cholesterol and triglycerides (pancreatitis, eruptive xanthoma, lipaemia retinalis).

What are the causes of hypercholesterolaemia?

• Primary hypercholesterolaemia: familial hypercholesterolaemia, familial combined hyperlipidaemia, polygenic hypercholesterolaemia

• Secondary hypercholesterolaemia: biliary cirrhosis, hypothyroidism, nephrotic syndrome, diet, drugs (thiazides, beta-blockers, oestrogens).

What is the histology of xanthomas?

Xanthomas are collections of foamy histiocytes within the dermis. These cells have abundant and finely vaculated cytoplasm giving it a foamy appearance. Cholesterol (both free and esterified), triglycerides and phospholipids are present within the cell. Often the cells are surrounded by inflammatory cells and fibrosis about the central zone of lipid-laden cells.

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