Lipid Cases

LIPID CASES Tutorial
Case
A 53 year-old Shilla, resident of South Delhi Hauz Khas, K/C/O DMT2, presented in the OPD with complains of
chest pain and breathlessness after climbing 2nd floor by stairs. Symptoms improved on taking rest. She used to
smoke cigarettes drink alcohol 2 pack/ Day since 26 yrs of age but quitted 1 year ago. Also, she gave family history
of DM & Hypertension. On examination, there was no pallor but yellow growth on inner side of both eyelids. Her
height was 170 cm, weight 85 kg, waist circumference 106 cm. Pulse rate: 98/min; regular Blood pressure: 160/110
mmHg. Lab results are:
BS F- 166mg/dL, TG – 300 mg/dL, HDL- 21 mg/dL, TC- 250 mg/dL
Xanthelasma
Q1. What is the diagnosis?

Ans: Diabetes Mellitus with Hyperlipidemia
Q2. Calculate the BMI & LDL and make inference (BMI= Wt in kg/Ht in m2)
BMI = 29.4
LDL-= 188 mg /dL
Q3. What would be the basic principle of management besides medicines?
Ans: Diabetes Mellitus should be controlled with regular follow up.
Life Style Modifications includes:
Weight reduction and maintenance of Ideal weight
Regular Physical Exercise
Stress Management - Yoga
Dietary Management includes
Calorie Restrictions up to 1500 cal/Day
Low fat Diet – 10-15 % of Total Calories
1. Saturated fatty acid: MUFA: PUFA = 1:3 as recommended by NCEP and AHA.
2. It should be a high fiber diet including leafy vegetables, beans, whole grain cereals, Oats etc.
3. It should have all the other essential components, including vitamins and minerals, etc.
Q4. What is the cause of Hyperlipidemia?
Ans. Due to insulin deficiency, glucose catabolism in peripheral tissues is decreased. To compensate for
energy requirements, lipolysis is stimulated because of high glucagon levels. Increased lipolysis leads to
increased fatty acid oxidation, resulting in excessive acetyl-CoA production. This acetyl-CoA enters into
various pathways, including cholesterol synthesis and triglyceride synthesis.
Q. What other investigations can be done ?
Ans : Extended Lipid Profile which consist of Lp(a), Apolipoprotein B & A1 ratio
Extra Edge :
Metabolic syndrome refers to the presence of a cluster of risk factors specific for cardiovascular disease. The
Criteria includes: 3/5 if fulfils
WC : 35/40 inch (M/W)
TG : ≥ 150 mg/dL
HTn : ≥130 mm Hg systolic BP/ ≥85 mm Hg diastolic BP
HDL : <40 mg/dL in men, <50 mg/dL in women
FBS: ≥100 mg/dL / Drug treatment
High Fiber Diet :Reduces Plasma Cholesterol by binding Bile salts & increases exceretion of Bile salts which
is a exceretory form of cholesterol.
Also it causes: Increase bulk of stool, Delays gastric emptying, Absorb large quantity of water, Decreases
glucose absorption.
CASE: 2
A Sikandar 7 year old boy resident of Amroha was brought to the OPD with whitish and firm eruptions on his
right elbow. They were identified as subcutaneous xanthomas. His mother said that his father had similar
symptoms and had died at the age of 32 years of a heart attack. The mother was worried about her son and
wanted to ensure that he does not develop heart disease. The results of investigations done were:
• Fasting blood sugar – 84 mg/dL
• Total cholesterol- 486 mg/dL
• LDL-C- 318 mg/dL
• HDL-C- 25 mg/dL
• TG- 118 mg/dL
Subcutaneous Xanthomas
Q.1. what is the probable diagnosis and its basis?

Ans. The most probable diagnosis is 'familial hypercholesterolemia'. It is also called type Ila
hyperlipoproteinemia. The raised cholesterol is due to a defect in the LDL receptor. The family history, high
cholesterol and LDL-C levels support it.
Q.2. what are its consequences?
Ans. This patient may develop premature atherosclerosis leading to coronary artery disease and myocardial
infarction and cerebrovascular stroke.
Q.3. what further evaluation is needed and what is the principle of management?
Ans. Careful evaluation of the heart should be done to know the present state of coronary artery disease by the
cardiologist.
Management would include:
A. Lowering of the lipid levels by suitable drugs.
B. Life style changes.
• Low fat, low sugar diet to maintain ideal weight.
• Avoiding animal fats and substitution of vegetable oils with a good mix of monounsaturated and
polyunsaturated fatty acids such as soya bean oil.
• Regular physical exercise.
• Avoiding smoking and alcohol intake.
Q.4. Name the common classes of lipid lowering drugs.
Which is the preferred drug these days and what are the target values of cholesterol and LDL-C?
Ans. • Resins - i.e., Cholestyramine
• Fibrates - Gemfibrozil, clofibrate
• HMG-CoA reductase inhibitors like statins
• Sitosterol
Cholestyramine or statins like simvastatin are commonly used. Cholestyramine enhances conversion of
cholesterol to bile acids and Bile salts. Simvastatin, by inhibiting HMG CoA synthase, decrease cholesterol
Synthesis. Both also upregulate upregulate LDL receptors.
Target LDL- C =100 mg/dL

Target TC- C = 200 mg/dL

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LIPID CASES Tutorial

Q1. What is the diagnosis?

Q.1. what is the probable diagnosis and its basis?

Target LDL- C =100 mg/dL

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