Rash in a Patient With New-Onset Type 1 Diabetes Mellitus.

An 18-year-old man with a body mass index of 20 kg/m2 and no prior medical diagnoses or medication use was evaluated by his primary care physician for an unintentional 40-pounds weight loss over the past year. Initial labs showed blood glucose of > 500 mg/dl, bicarbonate level of 14 mEq/L (normal, 22-29 mEq/L), anion gap of 26 mEq/L, 2+ urine ketones and 3+ urine glucose levels. He was referred to the Emergency Department where an Endocrinology consult was placed for further evaluation. At the time of presentation, his beta-hydroxybutyrate was 6.2 mEq/L (normal 0.0-0.3 mEq/L), lactic acid was 0.9 mmol/L (normal, 0.5-2.2 mmol/L), Hemoglobin A1c was 11.2%. He was started on an insulin infusion drip for diabetic ketoacidosis management. Family history was positive for diabetes mellitus in his paternal grandmother and hypertension in his father, but negative for dyslipidemia or premature cardiovascular disease. He does not smoke or drink alcohol. On examination, he had an erythematous papular skin rash, with papules ranging from 1-8 mm (Fig. 1, green arrows) over his arms and legs, for the past 4-5 months with an upcoming dermatologist outpatient evaluation. Eruptive xanthomas. Additional labs showed triglyceride level of > 9735 mg/dl. Triglyceride levels improved with NPO status and insulin drip. In this case, eruptive xanthomas were associated with severe hypertriglyceridemia and diabetic ketoacidosis (DKA) at time of diagnosis of type 1 diabetes mellitus. He was discharged on insulin therapy, fenofibrate 200 mg daily and omega-3 fatty acids 2g twice daily. Two weeks later, he followed up at the endocrine clinic, with noted improvement of his eruptive xanthomas. The patient has since missed return visits at our clinic, but was evaluated at an urgent care center 7 months later for chest and arms sunburn complaints, without mention of eruptive xanthoma findings on his skin physical exam. Few case reports of eruptive xanthomas at new-onset diabetes mellitus diagnosis have been published in pediatric patients (1Busch H. Nashed L.M. Neacsu O. Silverman R.A. Polyuria, Polydipsia and Papules in a 9-Year-Old Girl: A Case Report.J Pediatri Endocrinol. 2021; 6: 1047Google Scholar). Skin findings can be initially misdiagnosed as viral rash (2Alassaf A. Odeh R. Akl K.F. Xanthoma in a Child as the First Presentation of Type One Diabetes Mellitus.Pediat Therapeut. 2015; 5: 226Google Scholar) and referred for dermatologic evaluation which delays the time of diagnosis in a similar fashion to our case, increasing risks of complications including pancreatitis, DKA and cardiovascular comorbidities. With adequate treatment, resolution is reported to occur within weeks to several months. We highlight the importance of screening for diabetes and hypertriglyceridemia at initial visit for prompt therapy and genetic screening in indicated cases. Fibrates are the first line treatment of hypertriglyceridemia; statins are added based upon ASCVD risk. Insulin infusion therapy has been described in several literature reports as a method targeting concomitant hyperglycemia and hypertriglyceridemia management (3Poonuru S, Pathak SR, Vats HS, Pathak RD. Rapid reduction of severely elevated serum triglycerides with insulin infusion, gemfibrozil and niacin. Clin Med Res. 2011 Mar;9(1):38-41. doi: 10.3121/cmr.2010.898. Epub 2010 Sep 17Google Scholar).