Scientific letter
Primary hyperchylomicronemia syndrome treated with ciprofibrate in childhood
Síndrome de hiperquilomicronemia primaria tratado con ciprofibrato en la infancia
a Departamento de Ciencias Fisiológicas, Escuela de Ciencias de la Salud, Universidad de Oriente, Ciudad Bolívar, Venezuela
b Unidad de Endocrinología, Diabetes, Metabolismo y Nutrición, Anexo A, Centro Médico Orinoco, Ciudad Bolívar, Venezuela
c Consultorio Dermatológico «Lima-Ostos», Ciudad Bolívar, Venezuela
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"apellidos" => "Lima-Martínez" "email" => array:1 [ 0 => "marcoslimamedical@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Martha" "apellidos" => "Piñango" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Miguel" "apellidos" => "Lima-Ostos" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Ciencias Fisiológicas, Escuela de Ciencias de la Salud, Universidad de Oriente, Ciudad Bolívar, Venezuela" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Endocrinología, Diabetes, Metabolismo y Nutrición, Anexo A, Centro Médico Orinoco, Ciudad Bolívar, Venezuela" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Consultorio Dermatológico «Lima-Ostos», Ciudad Bolívar, Venezuela" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de hiperquilomicronemia primaria tratado con ciprofibrato en la infancia" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary hyperchylomicronemia syndrome or hyperlipoproteinemia type 1 (HLP-1) of the Fredrickson classification is a genetic disorder characterized by markedly increased triglyceride and chylomicron levels in blood which causes a high risk of pancreatitis and other complications.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> The syndrome is caused by mutations in the gene that encodes the enzyme lipoprotein lipase (LPL) or, less commonly, by mutations in genes encoding other proteins required for LPL function.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> The condition is usually diagnosed in childhood,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> an age for which the use of lipid lowering drugs is controversial.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a three-year-old girl with no family history of consanguinity or primary hyperlipidemia who was referred for severe hypertriglyceridemia (8492<span class="elsevierStyleHsp" style=""></span>mg/dL) and hypercholesterolemia (584<span class="elsevierStyleHsp" style=""></span>mg/dL) measured at two years and 10 months of age. A physical examination revealed 17<span class="elsevierStyleHsp" style=""></span>kg of weight, a height of 98<span class="elsevierStyleHsp" style=""></span>cm, and a body mass index of 17.7<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> (between the 90th and 97th percentiles). Eruptive xanthomas were found on the face, shoulders, buttocks, and upper and lower limbs. Eye fundus examination found <span class="elsevierStyleItalic">lipemia retinalis</span>, and abdominal palpation revealed hepatomegaly with no splenomegaly. Repeat lipid profile tests showed a lactescent plasma which contained 475<span class="elsevierStyleHsp" style=""></span>mg/dL of total cholesterol, 4727<span class="elsevierStyleHsp" style=""></span>mg/dL of triglycerides, and 32<span class="elsevierStyleHsp" style=""></span>mg/dL of HDL cholesterol. Lipoprotein electroforesis showed a marked elevation of chylomicrons only. A complete blood count disclosed normochromic, normocytic anemia (10.2<span class="elsevierStyleHsp" style=""></span>g/dL). An abdominal ultrasound examination confirmed hepatomegaly.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Based on the clinical signs and symptoms of the patient and on data from supplemental tests, the patient was diagnosed HLP-1 and prescribed a low-fat diet (18<span class="elsevierStyleHsp" style=""></span>g/day) and the addition of medium-chain triglycerides (30<span class="elsevierStyleHsp" style=""></span>mL daily in salads). Despite this, the patient was seen again after two months of treatment for abdominal pain, and testing revealed a triglyceride level of 3273<span class="elsevierStyleHsp" style=""></span>mg/dL. There was no elevation of liver enzymes or amylase. In view of the persistence of hypertriglyceridemia, the patient was prescribed ciprofibrate, 50<span class="elsevierStyleHsp" style=""></span>mg daily after supper, which achieved a significant clinical improvement at four months of treatment. Lipid levels were as follows: 191<span class="elsevierStyleHsp" style=""></span>mg/dL of total cholesterol, 169<span class="elsevierStyleHsp" style=""></span>mg/dL of triglycerides, 44<span class="elsevierStyleHsp" style=""></span>mg/dL of HDL cholesterol, and 112<span class="elsevierStyleHsp" style=""></span>mg/dL of LDL cholesterol. Transaminase and creatine phosphokinase levels were not increased.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A genetic analysis found no changes in the gene sequence of apolipoprotein C-II <span class="elsevierStyleItalic">(APOC2)</span>, apolipoprotein A-V <span class="elsevierStyleItalic">(APOA5)</span>, and <span class="elsevierStyleItalic">GPIHBP1</span> (the protein transporting LPL to capillaries, which serves as a platform for chylomicron hydrolysis mediated by this enzyme). Analysis of the LPL gene <span class="elsevierStyleItalic">(LPL)</span> showed a variant of the promoter 1-281C¿T which was not associated with any mutation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">After two years of treatment with ciprofibrate, the patient had not experienced new episodes of abdominal pain or new eruptive xanthomas. Lipid levels in the last assessment included 212<span class="elsevierStyleHsp" style=""></span>mg/dL of total cholesterol, 307<span class="elsevierStyleHsp" style=""></span>mg/dL of triglycerides, 112<span class="elsevierStyleHsp" style=""></span>mg/dL of LDL, and 37<span class="elsevierStyleHsp" style=""></span>mg/dL of HDL.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In children, hypertriglyceridemia is defined as plasma triglyceride levels above the 95th percentile for age and sex, and HLP-1 is the best example of severe hypertriglyceridemia.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> HLP-1 is a disorder of autosomal recessive inheritance, and the screening of first-degree relatives is therefore required. Our patient, however, had no siblings, and her parents had no lipid profile changes. It should be noted that the variant of the promoter 1-281C¿T in the <span class="elsevierStyleItalic">LPL</span> gene has not been reported in the literature, but it could not have caused the hypertriglyceridemia found in the patient because it causes no changes in the amino acid sequence and does not therefore impair LPL function. In this regard, Surendran et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> showed in 86 subjects with severe forms of hypertriglyceridemia that common variants were found in <span class="elsevierStyleItalic">LPL</span> and <span class="elsevierStyleItalic">APOA5</span> in 26% of cases, and that no mutation was found in 21%. These data open up new avenues for the study of novel candidate genes regulating triglyceride metabolism. No relationship exists between genotype and phenotype, but women with HLP-1 often experience anemia,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> which was also found in our patient.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The basic treatment consists of dietary fat restriction to no more than 20<span class="elsevierStyleHsp" style=""></span>g/day<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a>; in this pediatric patient, however, diet adherence was poor because of its low palatability. The use of medium-chain triglycerides is also recommended, because they enter the bloodstream without being incorporated into chylomicrons.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Fibric acid derivatives (fibrates) are recommended for the treatment of hypertriglyceridemia. These are agonists of the peroxisome proliferator-activated receptor alpha, and decrease extracellular triglyceride levels by inducing transcription of the <span class="elsevierStyleItalic">LPL</span> gene and reducing the expression of the apolipoprotein C-III gene, an LPL inhibitor.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> To our knowledge, no other case of HLP-1 treated with ciprofibrate has been reported in the literature. However, there is evidence of the effective and safe use of gemfibrozil 300<span class="elsevierStyleHsp" style=""></span>mg in two children with HLP-1 aged seven and four years.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Genotyping was not performed in these cases, but there is evidence that patients with a heterozygous mutation in <span class="elsevierStyleItalic">APOA5</span> respond adequately to medical treatment.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> It may thus be that the response to fibrates in patients with HLP-1 is dependent on the existence of significant residual LPL activity.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main adverse effects derived from the use of fibrates are gastrointestinal. Wheeler et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> conducted a prospective, randomized study in 14 children with familial hypercholesterolemia treated with bezafibrate and found good tolerability and no adverse effects on both growth and pubertal development.</p><p id="par0050" class="elsevierStylePara elsevierViewall">There is now evidence favoring the use of gene therapy in patients with HLP-1. Access to these new agents is limited, and the use of gene therapy requires the detection of the causative mutation in the <span class="elsevierStyleItalic">LPL</span> gene and the absence of LPL mass, so that our patient would have been discarded as a suitable candidate. Nutritional management combined with the use of fibrates may therefore be an effective and safe option in children with primary hyperchylomicronemia syndrome.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest related to this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:2 [ "identificador" => "xack208219" "titulo" => "Acknowledgments" ] 2 => array:1 [ "titulo" => "Refernces" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lima-Martínez MM, Piñango M, Lima-Ostos M. Síndrome de hiperquilomicronemia primaria tratado con ciprofibrato en la infancia. Endocrinol Nutr. 2016;63:98–99.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "Refernces" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Familial chylomicronemia syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Sugandhan" 1 => "S. Khandpur" 2 => "V.K. 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We also thank Sylvia Wertheim, from Novartis Venezuela, for her assistance in the literature review.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735093/0000006300000002/v1_201603200109/S2173509316000283/v1_201603200109/en/main.assets" "Apartado" => array:4 [ "identificador" => "5823" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735093/0000006300000002/v1_201603200109/S2173509316000283/v1_201603200109/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173509316000283?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 30 | 0 | 30 |
| 2024 October | 263 | 4 | 267 |
| 2024 September | 307 | 3 | 310 |
| 2024 August | 241 | 3 | 244 |
| 2024 July | 247 | 5 | 252 |
| 2024 June | 150 | 2 | 152 |
| 2024 May | 173 | 7 | 180 |
| 2024 April | 117 | 6 | 123 |
| 2024 March | 170 | 14 | 184 |
| 2024 February | 239 | 8 | 247 |
| 2024 January | 235 | 4 | 239 |
| 2023 December | 174 | 10 | 184 |
| 2023 November | 267 | 8 | 275 |
| 2023 October | 365 | 15 | 380 |
| 2023 September | 168 | 10 | 178 |
| 2023 August | 155 | 4 | 159 |
| 2023 July | 188 | 13 | 201 |
| 2023 June | 164 | 3 | 167 |
| 2023 May | 259 | 3 | 262 |
| 2023 April | 213 | 2 | 215 |
| 2023 March | 248 | 7 | 255 |
| 2023 February | 137 | 7 | 144 |
| 2023 January | 126 | 6 | 132 |
| 2022 December | 118 | 12 | 130 |
| 2022 November | 166 | 9 | 175 |
| 2022 October | 177 | 14 | 191 |
| 2022 September | 134 | 18 | 152 |
| 2022 August | 144 | 24 | 168 |
| 2022 July | 125 | 19 | 144 |
| 2022 June | 112 | 6 | 118 |
| 2022 May | 104 | 18 | 122 |
| 2022 April | 71 | 10 | 81 |
| 2022 March | 118 | 15 | 133 |
| 2022 February | 104 | 14 | 118 |
| 2022 January | 172 | 7 | 179 |
| 2021 December | 134 | 9 | 143 |
| 2021 November | 86 | 12 | 98 |
| 2021 October | 132 | 22 | 154 |
| 2021 September | 76 | 20 | 96 |
| 2021 August | 112 | 12 | 124 |
| 2021 July | 71 | 14 | 85 |
| 2021 June | 113 | 16 | 129 |
| 2021 May | 118 | 12 | 130 |
| 2021 April | 347 | 19 | 366 |
| 2021 March | 176 | 28 | 204 |
| 2021 February | 201 | 12 | 213 |
| 2021 January | 187 | 17 | 204 |
| 2020 December | 238 | 19 | 257 |
| 2020 November | 142 | 13 | 155 |
| 2020 October | 126 | 11 | 137 |
| 2020 September | 198 | 16 | 214 |
| 2020 August | 143 | 15 | 158 |
| 2020 July | 106 | 19 | 125 |
| 2020 June | 119 | 16 | 135 |
| 2020 May | 90 | 21 | 111 |
| 2020 April | 100 | 8 | 108 |
| 2020 March | 94 | 15 | 109 |
| 2020 February | 94 | 8 | 102 |
| 2020 January | 82 | 5 | 87 |
| 2019 December | 83 | 6 | 89 |
| 2019 November | 70 | 12 | 82 |
| 2019 October | 76 | 2 | 78 |
| 2019 September | 82 | 14 | 96 |
| 2019 August | 51 | 9 | 60 |
| 2019 July | 72 | 12 | 84 |
| 2019 June | 135 | 30 | 165 |
| 2019 May | 301 | 60 | 361 |
| 2019 April | 201 | 36 | 237 |
| 2019 March | 34 | 12 | 46 |
| 2019 February | 45 | 13 | 58 |
| 2019 January | 50 | 4 | 54 |
| 2018 December | 40 | 3 | 43 |
| 2018 November | 42 | 16 | 58 |
| 2018 October | 53 | 6 | 59 |
| 2018 September | 38 | 12 | 50 |
| 2018 August | 12 | 9 | 21 |
| 2018 July | 11 | 3 | 14 |
| 2018 June | 11 | 4 | 15 |
| 2018 May | 10 | 16 | 26 |
| 2018 April | 6 | 2 | 8 |
| 2018 March | 12 | 1 | 13 |
| 2018 February | 12 | 1 | 13 |
| 2018 January | 21 | 1 | 22 |
| 2017 December | 10 | 3 | 13 |
| 2017 November | 20 | 4 | 24 |
| 2017 October | 13 | 2 | 15 |
| 2017 September | 13 | 5 | 18 |
| 2017 August | 19 | 12 | 31 |
| 2017 July | 13 | 2 | 15 |
| 2017 June | 20 | 13 | 33 |
| 2017 May | 37 | 14 | 51 |
| 2017 April | 19 | 7 | 26 |
| 2017 March | 35 | 15 | 50 |
| 2017 February | 37 | 7 | 44 |
| 2017 January | 18 | 6 | 24 |
| 2016 December | 14 | 8 | 22 |
| 2016 November | 21 | 5 | 26 |
| 2016 October | 45 | 14 | 59 |
| 2016 September | 27 | 1 | 28 |
| 2016 August | 36 | 3 | 39 |
| 2016 May | 0 | 1 | 1 |
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