Most patients with high cholesterol levels have no specific symptoms or signs. The vast majority of patients with lipid abnormalities are detected by the laboratory, either as part of the workup of a patient with CVD or as part of a preventive screening strategy. Extremely high levels of chylomicrons or VLDL particles (triglyceride level above 1000 mg/dL or 10 mmol/L) result in the formation of eruptive xanthomas (Figure 28–1) (red-yellow papules, especially on the buttocks [eFigure 28–2]). High LDL concentrations result in tendinous xanthomas on certain tendons (Achilles, patella, back of the hand [eFigures 28–3, 28–4, 28–5]). Such xanthomas usually indicate one of the underlying genetic hyperlipidemias. Lipemia retinalis (cream-colored blood vessels in the fundus) is seen with extremely high triglyceride levels (above 2000 mg/dL or 20 mmol/L).
Eruptive xanthomas on the arm of a man with untreated hyperlipidemia and diabetes mellitus. (Used, with permission, from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas and Synopsis of Family Medicine, 3rd ed. McGraw-Hill, 2019.)
Eruptive xanthoma. (Used, with permission, from Marvin D. Siperstein, MD.)
Clinical manifestations of hyperlipidemias. A: Xanthelasma involving medial and lateral canthi. B: Severe xanthelasma and arcus corneae. C: Tuberous xanthomas. D: Large tuberous xanthoma of elbow. E: Eruptive xanthomas, singly and in rosettes. F: Xanthomas of extensor tendons of the hands. G: Xeroradiogram of Achilles tendon xanthoma. H: Xanthoma of Achilles tendon (normal Achilles tendons do not exceed 7 mm in diameter in the region between the calcaneus and the point at which the tendon fibers begin to radiate toward their origins). (Reproduced, with permission, from Gardner DG, Shoback D [editors]. Greenspan's Basic & Clinical Endocrinology, 10th ed. Copyright © 2018 McGraw-Hill Education, 2018.)
Tendinous xanthomas: elbow xanthomas. (Used, with permission, from Marvin D. Siperstein, MD.)
Tendinous xanthomas: knuckle xanthomas. (Used, with permission, from Marvin D. Siperstein, MD.)