The n e w e ng l a n d j o u r na l
Images in Clinical Medicine
Viktoria F. Koehler, M.D.
Klaus G. Parhofer, M.D.
Klinikum der Universität München
Munich, Germany
klaus​.­parhofer@​­med​.­uni-muenchen​.­de
e26
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Copyright © 2018 Massachusetts Medical Society. All rights reserved.
of m e dic i n e
Chana A. Sacks, M.D., Editor
Xanthoma Striatum Palmare
A 
49-year-old man was referred to the metabolic clinic for eval-
uation of severe hypercholesterolemia and xanthomas, which were particu-
larly prominent on the hands. The lesions were painful and affected the
patient’s everyday life, making it difficult for him to open bottles or shake hands.
He had a 2-year history of biliary cirrhosis due to ischemic cholangiopathy. Labora-
tory evaluations showed a total cholesterol level of 970 mg per deciliter (25.1 mmol
per liter); a triglyceride level of 158 mg per deciliter (1.8 mmol per liter); a low-
density lipoprotein (LDL) cholesterol level of 875 mg per deciliter (22.6 mmol per
liter), with presence of lipoprotein-X; and a high-density lipoprotein cholesterol
level of 64 mg per deciliter (1.7 mmol per liter). Treatment with LDL apheresis was
started. Palmar xanthomas can also be seen in patients with type III hyperlipo-
proteinemia (familial dysbetalipoproteinemia). Xanthomas are rarely so severe that
they interfere with activities of daily life. Within 3 months after the initiation of
weekly LDL apheresis, the lesions had almost disappeared and the patient reported
substantial relief from pain and improvement in function. At follow-up 10 years
after presentation, the patient was in stable condition and was undergoing LDL
apheresis every other week. Since the initiation of LDL apheresis, his LDL choles-
terol level had decreased to 110 mg per deciliter (2.8 mmol per liter).
DOI: 10.1056/NEJMicm1713658
Copyright © 2018 Massachusetts Medical Society.
n engl j med 378;19 nejm.org  May 10, 2018
The New England Journal of Medicine