A 42-year-old woman comes to the physician for a routine check-up. She has no current complaints and no significant past medical history. On physical examination, the physician notes lesions on her eyelids that are pictured below. Which of the following is the best next step in the management of this patient?

Question

A 42-year-old woman comes to the physician for a routine check-up.  She has no current complaints and no significant past medical history.  On physical examination, the physician notes lesions on her eyelids that are pictured below.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

The lesion pictured is a xanthelasma, a type of xanthoma usually found on the medial eyelids. Hyperlipidemia and/or dyslipidemia can result in xanthomas (including xanthelasmas). Xanthelasmas are dermal accumulations of benign-appearing macrophages with abundant, finely vacuolated (foamy) cytoplasm containing cholesterol (free and esterified), phospholipids, and triglycerides. Due in part to insulin resistance promoting increased VLDL production, diabetics may develop a secondary Type IV or V hyperlipidemia (increased VLDL, chylomicrons) and/or a secondary diabetic dyslipidemia with elevated LDL cholesterol and low HDL cholesterol. Thus, in order to determine the type of this patient's lipid disorder and to rule out underlying diabetes, her serum lipids and blood glucose should be measured. (Choice A) Although this patient may be at increased risk for coronary artery disease due to hyperlipidemia or dyslipidemia, she does not currently have symptoms of myocardial infarction. Her current management should be focused on treating her lipid disorder. (Choice C) The first step in managing this patient is to establish what type of lipid abnormality she has based upon her serum lipid levels and lipoprotein profile. If the results are consistent with an obstructive liver and/or biliary system lesion producing cholestasis and hypercholesterolemia, then liver function tests and abdominal ultrasonography may be warranted. (Choice D) A CBC and stool guaiac test are performed when searching for occult GI bleeding. (Choice E) Slit lamp examination and funduscopy could reveal ocular findings associated with this patient's lipid disorder, such as a corneal arcus (lipid deposit) or lipemia retinalis. However, a serum lipid profile should be obtained next in order to establish the type of hyperlipidemia or dyslipidemia in this patient. (Choice F) Xanthelasmas are usually diagnosed based on clinical appearance. Biopsy is not required. Treatment is primarily medical and directed at the underlying lipid abnormality. Surgical excision is not medically necessary, but may be undertaken electively for cosmetic reasons. Educational objective: Xanthelasmas, a type of xanthoma, are yellowish macules/papules found on the medial eyelids. They are dermal accumulations of macrophages containing cholesterol and triglycerides, and are generally associated with a primary or secondary hyperlipidemia or dyslipidemia. An LDL receptor abnormality is the most common cause.

A 42-Year-Old Woman Comes to the Physician for a Routine