This 5-year-old girl presented with new onset type 1 diabetes mellitus, diabetic ketoacidosis (DKA), and hypothyroidism, and this was associated with significant hyperlipidaemia. Her clinical course was complicated by DVT secondary to hyperlipidaemia, hyperviscosity and the presence of femoral line. Her lipid profile normalised 2 months following commencement of insulin and L-thyroxine therapy.
Lipid abnormalities are common in children with new onset diabetes mellitus with DKA,1
and treatment with insulin leads to its resolution over a few weeks.1–4
In addition, isolated hypothyroidism can be associated with hyperlipidaemia.5
The severity of hyperlipidaemia seen in our patient is rare and is likely due to the simultaneous presence of diabetes and hypothyroidism of uncertain duration. As regards to the potential mechanisms involved in causing such a significant degree of hyperlipidaemia, it has been proposed that insulin deficiency, alone or in association with LPL gene mutations, results in impaired lipoprotein lipase action in adipose tissue and reduced lipid clearance.1,6,7
Regarding the management of severe hyperlipidaemia with DKA, plasmapheresis and other methods of lipid separation from plasma do have a role in management.8
Plasmapheresis removes excess lipids, improves metabolic acidosis, reduces plasma viscosity and the risk of pancreatitis and thrombosis. It was considered early in our patient but as the plasma lipid profile, metabolic acidosis, and clinical condition were improving it was withheld.
One of the significant complications that our patient had was DVT despite prophylactic anticoagulant use. Tinzaparin reduces the risk of thrombosis, releases lipoprotein lipase to the circulation, and reduces the concentration of circulating chylomicrones.5
However, it did not prevent DVT in this case, but this could be due to multiple factors including unknown duration of illness with dehydration, acidosis, hyperlipidaemia, hyperviscosity and central access. Early anticoagulant use is important in these cases and careful monitoring for the development of thrombosis is necessary to allow early intervention; benefits of central vascular access should be weighed carefully against potential risk of thrombosis. To our knowledge, this is the first reported case with profound hyperlipidaemia secondary to concomitant diabetes and hypothyroidism. We propose that a lipid profile needs to be considered when diabetes and hypothyroidism coexist to facilitate the detection and early intervention to correct hyperlipidaemia, and to avoid potential complications.
- Profound hyperlipidaemia is a rare but serious complication of diabetic ketoacidosis.
- The association of hypothyroidism needs to be considered in this case.
- Prophylactic anticoagulant therapy should be implemented and careful monitoring is essential to detect and treat thrombotic events.
- A lipid profile needs to be considered when concomitant diabetes and hypothyroidism are present to allow early detection and intervention.