Severe hypercholesterolemia mediated by lipoprotein X in a patient with cholestasis
Dineo V. Phatlhane, Annalise E. Zemlin
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Department of Chemical Pathology, National Health Laboratory Service (NHLS) and University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
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"documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "mis" "cita" => "Ann Hepatol. 2015;14:919-23" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 134 "formatos" => array:3 [ "EPUB" => 21 "HTML" => 63 "PDF" => 50 ] ] "en" => array:9 [ "idiomaDefecto" => true "titulo" => "Congenital double intrahepatic portosystemic shunt: Imaging findings and endovascular closure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "919" "paginaFinal" => "923" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 783 "Ancho" => 1045 "Tamanyo" => 74403 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Transjugular portography performed after catheterization of the splenic (A) and right portal vein (B) through the PDV and during balloon occlusion test (C and D) [digital subtraction images on coronal projection]. A and B. Portograms show the high-flow in the larger fistula (arrow) and better highlight the smaller shunt with Y shape arising from the hypoplastic right portal vein and directing to the subdiaphragmatic inferior vena cava (white arrow head and thin arrows). No intrahepatic portal venous branch was visualized. C and D. Angiograms during occlusion test with Swan-Ganz catheter balloon inflated within the PDV (black arrow head) show the opacification of the entire intrahepatic portal venous branches and suprahepatic veins too. rsv: right suprahepatic vein. msv: middle suprahepatic vein. lsv: left suprahepatic vein.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Guglielmo Paolantonio, Andrea Pietrobattista, Manila Candusso, Lidia Monti, Jean de Ville de Goyet, Giuliano Torre, Massimo Rollo" "autores" => array:7 [ 0 => array:3 [ "preGrado" => "M.D." "nombre" => "Guglielmo" "apellidos" => "Paolantonio" ] 1 => array:2 [ "nombre" => "Andrea" "apellidos" => "Pietrobattista" ] 2 => array:2 [ "nombre" => "Manila" "apellidos" => "Candusso" ] 3 => array:2 [ "nombre" => "Lidia" "apellidos" => "Monti" ] 4 => array:2 [ "nombre" => "Jean de Ville de" "apellidos" => "Goyet" ] 5 => array:2 [ "nombre" => "Giuliano" "apellidos" => "Torre" ] 6 => array:2 [ "nombre" => "Massimo" "apellidos" => "Rollo" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119309627?idApp=UINPBA00004N" "url" => "/16652681/0000001400000006/v1_201906050954/S1665268119309627/v1_201906050954/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "titulo" => "Severe hypercholesterolemia mediated by lipoprotein X in a patient with cholestasis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "924" "paginaFinal" => "928" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Dineo V. Phatlhane, Annalise E. Zemlin" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Dineo V." "apellidos" => "Phatlhane" ] 1 => array:5 [ "preGrado" => "MBChB, FCPath (SA) (Chem), MMed (Chem Path)" "nombre" => "Annalise E." "apellidos" => "Zemlin" "email" => array:1 [ 0 => "azemlin@sun.ac.za" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Chemical Pathology, National Health Laboratory Service (NHLS) and University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 342 "Ancho" => 503 "Tamanyo" => 14951 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Polyacrylamide non-denaturing gradient gel lipoprotein electrophoresis. Lane 1, patient sample. The LpX band is of narrower size range than VLDL and often found in the mid region (as above). The LDL species in this patient of intermediate size and very low concentration (estimate of < 0.5 mmol/L).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Lipoprotein X (LpX) is an abnormal lipoprotein rich in phospholipids and unesterified cholesterol with albumin as the main protein. It was first decribed in the 19th century in patients with obstructive jaundice and elevated serum lipids. Further studies attributed this to the presence of an abnormal low density lipoprotein (LDL); however this abnormal lipoprotein was only isolated and characterized in the late sixties in patients with biliary obstruction.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It was also found that experimentally induced cholestasis in animals led to a rapid increase in LpX which normalised within a week after alleviation of cholestasis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It was suggested that LpX originated from reflux of bile lipoprotein into the plasma leading to decreased catabolism of this intestinal lipoprotein.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> We present a case of severe hypercholesterolemia in a patient with cholestatic liver disease.</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Case Report</span><p id="p0010" class="elsevierStylePara elsevierViewall">A 46 year old female patient was referred from her local clinic to Tygerberg Hospital in February 2014 with a history of persistently deranged liver function tests since October 2013. She was known with human immunodeficiency virus 1 (HIV-1) since 1997 and has been on co-trimoxazole (Bactrim) therapy since 1998. She is a known hypertensive on enalapril and has a previous history of abdominal tuberculosis (TB), having completed her anti-TB therapy in May 2013. Anti-retroviral therapy (ART) was initiated in August 2013 consisting of efavirenz (EFZ), lamivudine (3TC) and zidovudine (AZT). At the time of initiation of ART her latest CD4 T cell count was 510 (cells/mm<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>).</p><p id="p0015" class="elsevierStylePara elsevierViewall">She was followed up monthly since August 2013 at the clinic and her full blood count, liver and renal functions were monitored. In October 2013, for unknown reasons, a full liver function test was performed and a cholestatic picture with raised alkaline phosphatase (ALP) and gamma glutamyl-transferase (GGT) but no hyperbilirubinaemia was detected. The cholestasis deteriorated over the next 3 months (<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>). Hepatitis studies were performed in January 2014 and were found to be negative for Hepatitis B and C. The patient was then referred to the infectious diseases clinic at Tyger-berg Hospital.</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><p id="p0020" class="elsevierStylePara elsevierViewall">At the time of the initial presentation at Tygerberg Hospital in February 2014, the patient did not report any history of abdominal pain, constitutional symptoms or jaundice. On the physical examination, there was no jaundice, oral candidiasis and anemia. Her blood pressure was 180/100 mmHg, pulse rate 82, capillary glucose 4.7 mmol/l and her body mass index 21.8 kg/m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. There was no evidence of hepatomegaly on abdominal examination and the rest of the systemic examination was within normal limits. A provisional diagnosis of steatohepatitis secondary to Zidovudine was made. An abdominal sonar was requested and bloods were collected for liver function tests (<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>). The co-trimoxazole was stopped and her ART was changed to the standard first line therapy consisting of efavirenz (EFZ), emtracitabine (FTC), tenofivir (TDF).</p><p id="p0025" class="elsevierStylePara elsevierViewall">One week later, at the follow up visit, the patient did not report any problems on the new regimen. A lipogram was requested and the total cholesterol was 5.5 mmol/l with a triglyceride value of 1.9 mmol/l (<a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>). It is not clear if the patient was fasting at the time of blood collection. The abdominal sonar demonstrated a fatty infiltration of the liver.</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0030" class="elsevierStylePara elsevierViewall">The patient was followed up monthly and over the next three months the liver enzymes progressively worsened with development of hyperbilirubinemia and mildly elevated transaminases (<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>). The liver biopsy, in May 2014, revealed a granulomatous hepatitis with focal necrotising granulomas, associated fibrosis and portal tract fibrosis. Hepatitis B and C serology was repeated and it remained negative. Her blood pressure was poorly controlled and a second antihypertensive agent i.e. amlodipine was added.</p><p id="p0035" class="elsevierStylePara elsevierViewall">Two weeks following the biopsy, a severe hypercholesterolemia was detected with a total cholesterol value of 32.3 mmol/l (<a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>). On physical examination there was no evidence of xanthelasma, arcus or tendon xanthomata that may suggest familial hypercholesterolemia. Hypothyroidism and nephrotic syndrome were excluded, based on the absence of clinical signs with normal thyroid stimulating hormone and urine protein respectively. The severe hypercholesterolemia was thought to be due to LpX and lipoprotein agarose gel electrophoresis was performed. The lipoprotein agarose gel electrophoresis was not diagnostic of LpX. There was intense staining of the beta area with minor cathodic migration and the beta band had a slight green tinge (<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>). However, LpX was demonstrated by gradient gel electrophoresis (<a class="elsevierStyleCrossRef" href="#f0010">Figure 2</a>). The bile acids were determined and found to be increased. The 3α-hydroxy sterol concentration in our patient was 322.3 <span class="elsevierStyleItalic">μ</span>mol/l (reference range < 10 <span class="elsevierStyleItalic">μ</span>mol/l).</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0040" class="elsevierStylePara elsevierViewall">A repeat liver biopsy was performed in June 2014 with the intention to send a specimen to Microbiology for TB culture. However, the sample was only sent to histopathology. The liver biopsy showed a granulomatous hepatitis and the stains were negative for TB, fungal spores and hyphae, amyloidosis, iron and copper deposition. Although there was no clinical evidence of sarcoidosis, determination of angiotensin converting enzyme (ACE) was done to exclude sarcoidosis. The ACE concentration was below the detectable limit (< 8 U/l). Blood, sputum and urine cultures were all negative for TB. However, the patient was started on empiric TB treatment in June 2014, and this resulted in a significant improvement of liver function tests (<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>) and normalisation of the lipid profile (<a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>). She also had a mild hyponatremia which has now normalised. She continues to follow up monthly.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Discussion</span><p id="p0045" class="elsevierStylePara elsevierViewall">Hypercholesterolemia is a common finding in adults and it is one of the major causes of coronary artery disease. Most cases of hypercholesterolemia are multifactorial with obesity, a high fat diet and an underlying polygenic predisposition as the major contributors. Hypercholesterolemia is typically categorised into primary and secondary causes. Primary causes of hypercholesterolemia are due a genetic component and include conditions like familial hypercholesterolemia (FH).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Secondary causes of hypercholesterolemia must always be excluded. The major causes are hypothyroidism, nephrotic syndrome and liver disease. In such cases therapy is directed towards the primary disorder however statin therapy or plasma apheresis may be required in some patients.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0050" class="elsevierStylePara elsevierViewall">The liver plays an important role in lipid metabolism. Therefore, abnormal liver functions can result in abnormal plasma lipids, lipoproteins and apolipoproteins.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Hypercholesterolemia associated with liver disease was first described by Flint in 1862, in patients with obstructive jaundice. However, the mechanisms or the lipoprotein responsible for the elevated cholesterol levels was not known. In 1969, Siedel, <span class="elsevierStyleItalic">et al.</span> designated this lipoprotein associated with biliary obstruction as LpX. The lipoprotein pattern of these patients was characterised by an increased LDL concentration and a decreased high density lipoprotein (HDL) concentration.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0055" class="elsevierStylePara elsevierViewall">LpX is a low density lipoprotein and it is made up largely of phospholipids (66 %) and unesterified cholesterol (22%) with very little triglyceride (3%), cholesterol ester (3%) and protein content (6%). The protein component of LpX is made up of albumin found within its core, which makes up to 60% of the protein content, and apolipoprotein C located on the surface.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Despite the characterization of LpX, much was not known about its metabolism. It was postulated that LpX originated from intestinal mucosa and is normally undetectable in the blood during the fasting state, due to the rapid degradation in the liver. In obstructive jaundice, the increase in LpX was thought to be due to increased bile acids resulting in inhibition of catabolic reactions of LpX.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0060" class="elsevierStylePara elsevierViewall">LpX is found in various liver diseases associated with cholestasis. It has been found, amongst others, in primary biliary cirrhosis, bile duct obstruction, chronic grafft-<span class="elsevierStyleItalic">vs.</span>-host disease of the liver as well as viral and drug induced hepatitis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="p0065" class="elsevierStylePara elsevierViewall">A literature search revealed that hypercholesterolemia in granulomatous hepatitis has only been described once in two cases written up in 1976. However, in both cases the hypercholesterolemia was not as severe as in our patient; it developed a few years following a splenorenal shunt procedure and resolved on a low cholesterol diet. The lipoprotein electrophoresis of both patients showed a Type IIa pattern i.e. an abnormal increase in LDL.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0070" class="elsevierStylePara elsevierViewall">Unlike LDL, LpX is not taken up by the liver; it is instead cleared by the reticuloendothelial system particularly the spleen. Therefore, it is unable to exert negative feedback on the cholesterol synthesis rate limiting enzyme hydroxymethyglutaryl coenzyme A (HMG-CoA) reductase. In contrast, the presence of LpX increases the activity of HMG-CoA reductase in the liver with increased hepatic cholesterol synthesis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="p0075" class="elsevierStylePara elsevierViewall">Pseudohyponatremia has been described in cases of increased LpX.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> This falsely decreased sodium concentration occurs when sodium is measured on an analyser that uses indirect ion-selective electrode potentiometry. A normal measured serum osmolality in the face of hyponatremia should point to the presence of pseudohyponatraemia. Measurement of sodium with an analyser that uses direct ion-selective electrode potentiometry, e.g. blood gas analyser, would be advised in patients with LpX.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> LpX has also been found to interfere with measured (direct) and calculated LDL cholesterol.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Our patient had borderline decreased sodium which may have been due to this, but was never investigated. As the sodium levels returned to normal we presume there was an element of pseudohyponatremia.</p><p id="p0080" class="elsevierStylePara elsevierViewall">Complications of LpX include development of xanthomata, retinal cholesterol, thromboembolism, cholesteroloma of the lung and hyperviscosity syndrome.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Although cholesterol levels are extremely high in cases of raised LpX, patients with chronic cholestasis such as primary biliary cirrhosis do not have a significantly increased incidence of coronary artery disease. It has been described that LpX may in fact have an anti-atherogenic effect by decreasing LDL oxidation. This is thought to be due to the high phospholipid content of LpX. This protective effect decreased after liver transplantation and normalization of LpX levels.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Patients with LpX do not usually require therapy, however very high concentrations of LpX can result in the above mentioned complications which require therapy. The first choice therapy in complicated cases of LpX is LDL apheresis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="p0085" class="elsevierStylePara elsevierViewall">The presence of LpX can be detected on agar-gel electrophoresis. LpX migrates towards the cathode on agar-gel electrophoresis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Nuclear magnetic resonance spectroscopy, ultracentrifugation, chemical and immunological assays are alternative methods for the determination of LpX.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> We failed to demonstrate the presence of LpX on agarose gel elec-trophoresis; however it was confirmed on gradient gel electrophoresis.</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Conclusion</span><p id="p0090" class="elsevierStylePara elsevierViewall">We describe an unusual case of severely increased cholesterol levels in a patient with cholestasis due to the presence of LpX. The cholesterol levels normalised with improvement of the cholestasis. This patient also had decreased sodium levels which may be due to pseudohyponatremia associated with this condition. Although LpX was described over a century ago, there is a lack of understanding about its effects and clinicians often seem to miss this condition. Laboratory staff and clinicians need to be aware of the possible causes of increased LpX.</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Abbreviations</span><p id="p0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0005"><li class="elsevierStyleListItem" id="u0005"><span class="elsevierStyleLabel">•</span><p id="p0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ART</span>: antiretroviral therapy.</p></li><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">•</span><p id="p0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LDL</span>: low density lipoprotein.</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">•</span><p id="p0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LpX</span>: lipoprotein X.</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">•</span><p id="p0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">TB</span>: tuberculosis.</p></li></ul></p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Consent</span><p id="p0120" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Conflict of Interest</span><p id="p0125" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest associated with this work.</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Acknowlegements</span><p id="p0130" class="elsevierStylePara elsevierViewall">We would like to thank Dr. Hugo for the clinical information of the patient; UCT lipid laboratory staff for the determination of the gradient gel electrophoresis and bile acids; Prof. David Marais and Dr. Dirk Blom for the clinical input and interpretation of both the lipoprotein agarose and gradient gel electrophoresis.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1199886" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0010" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1118322" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "s0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "s0010" "titulo" => "Case Report" ] 4 => array:2 [ "identificador" => "s0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "s0020" "titulo" => "Conclusion" ] 6 => array:2 [ "identificador" => "s0025" "titulo" => "Abbreviations" ] 7 => array:2 [ "identificador" => "s0030" "titulo" => "Consent" ] 8 => array:2 [ "identificador" => "s0035" "titulo" => "Conflict of Interest" ] 9 => array:2 [ "identificador" => "s0040" "titulo" => "Acknowlegements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-22" "fechaAceptado" => "2015-03-04" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1118322" "palabras" => array:5 [ 0 => "Cholesterol" 1 => "Granuloma" 2 => "Hepatitis" 3 => "Pseudohyponatremia" 4 => "Electrophoresis" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Lipoprotein X (LpX) is an abnormal lipoprotein associated with cholestasis. It is a significant cause of severe hypercholesterolemia and should always be considered in patients with cholestatic liver disease. This case highlights the significance of LpX as a cause of severe hypercholesterolemia in a patient with cholestasis secondary to a granulomatous hepatitis attributed to tuberculosis. Lipoprotein agarose gel electrophoresis and gradient gel electrophoresis were performed for the detection of LpX. The liver function tests, electrolytes, lipid profile and bile acids were also determined. Anti-tuberculous therapy was initiated and the liver functions improved with normalisation of the lipid profile.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 217 "Ancho" => 503 "Tamanyo" => 10037 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Agarose gel lipoprotein electrophoresis. Lane 1, patient sample; Lane 6, control sample. Intense staining of the beta area with minor cathodic migration. The beta area has a green tinge which is often seen with LpX.</p>" ] ] 1 => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 342 "Ancho" => 503 "Tamanyo" => 14951 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Polyacrylamide non-denaturing gradient gel lipoprotein electrophoresis. Lane 1, patient sample. The LpX band is of narrower size range than VLDL and often found in the mid region (as above). The LDL species in this patient of intermediate size and very low concentration (estimate of < 0.5 mmol/L).</p>" ] ] 2 => array:7 [ "identificador" => "t0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="np0005" class="elsevierStyleSimplePara elsevierViewall">ALP: alkaline phosphatase. GGT: γ-glutamyl transferase. AST: aspartate transaminase. ALT: alanine transaminase.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Analyte \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference range \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">October<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> 2013 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">February<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">†</span></a> 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">May<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">‡</span></a> 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">June<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">§</span></a> 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">August 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">September 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">October 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total bilirubin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-21 umol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Direct bilirubin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-6 umol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ALP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40-120 U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">489 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,059 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,434 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,537 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">804 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">495 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">481 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GGT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1-24 U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">805 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">862 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,051 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,361 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">721 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">450 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5-40 U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">102 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ALT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5-40 U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">135-147 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">133 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">137 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Albumin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35-52 g/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total protein \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60-85 g/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2049672.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">2 months post ART initiation.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "†" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Initial presentation at Tygerberg Hospital.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "‡" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Liver biopsy performed.</p>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "§" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Repeat liver biopsy and initiation of empiric anti-TB therapy.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Serum biochemistry results.</p>" ] ] 3 => array:7 [ "identificador" => "t0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="np0010" class="elsevierStyleSimplePara elsevierViewall">HDL: high density lipoprotein. LDL: low density lipoprotein.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Analyte \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference range \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">February 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">June 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">August 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">October 2014 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total cholesterol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">< 5 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Triglycerides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5-1.5 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HDL cholesterol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 1.2 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LDL cholesterol<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2049671.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Calculated using Friedewald formula: LDL = TC - HDL- (TG/2.2). February, 1 week follow up at Tygerberg Hospital. June, before initiation of anti-TB therapy. August, 5 weeks on anti-TB therapy. October, 4 months on TB treatment.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Lipid profile results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0010" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A lipoprotein characterizing obstructive jaundice. I. Method for quantitative separation and identification of lipoproteins in jaundiced subjects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Seidel D." 1 => "Alaupovic P." 2 => "Furman R.H." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1172/JCI106085" "Revista" => array:6 [ "tituloSerie" => "J Clin Invest" "fecha" => "1969" "volumen" => "48" "paginaInicial" => "1211" "paginaFinal" => "1223" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4978447" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Occurrence of an abnormal lipoprotein in patients with liver disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Ross A." 1 => "Murphy G.M." 2 => "Wilkinson P.A." 3 => "Mills G.L." 4 => "Sherlock S." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gut" "fecha" => "1970" "volumen" => "11" "paginaInicial" => "1035" "paginaFinal" => "1037" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5511783" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3." 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| Year/Month | Html | Total | |
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| 2024 November | 8 | 0 | 8 |
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| 2023 September | 75 | 10 | 85 |
| 2023 August | 82 | 33 | 115 |
| 2023 July | 98 | 15 | 113 |
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| 2022 December | 60 | 9 | 69 |
| 2022 November | 99 | 13 | 112 |
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| 2020 December | 54 | 12 | 66 |
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| 2020 March | 50 | 14 | 64 |
| 2020 February | 38 | 12 | 50 |
| 2020 January | 54 | 21 | 75 |
| 2019 December | 38 | 5 | 43 |
| 2019 November | 16 | 5 | 21 |
| 2019 October | 12 | 1 | 13 |
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