Severe Hypertriglyceridemia With Lipemia-Induced Analytical Interference

Figures

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  Visual Summary. Severe Hypertriglyceridemia With Lipemia-Induced Analytical Interference and Multisystem Clinical Presentation This illustration summarizes the diagnostic and clinical complexity in a patient with severe hypertriglyceridemia presenting with acute coronary syndrome and recent imaging-confirmed acute pancreatitis. Severe lipemia resulted in significant analytical interference affecting coagulation assays and biochemical measurements, including discordant pancreatic enzyme levels. The figure highlights the interplay between triglyceride-rich lipoprotein excess, laboratory assay interference, and multisystem involvement, emphasizing challenges in clinical interpretation and decision-making in severe hypertriglyceridemia. apoB = apolipoprotein B; BMI = body mass index; HDL = high-density lipoprotein; INR = international normalized ratio; LAD = left anterior descending artery; MRCP = magnetic resonance cholangiopancreatography; PCI = percutaneous coronary intervention; PT = prothrombin time; TG = triglycerides; VLDL = very-low-density lipoprotein.

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  Figure 1. Diagnostic Evaluation of the Patient Arrows indicate key findings. (A) Electrocardiogram from an outside facility showing biphasic T waves in leads V2 and V3 and T-wave inversion in leads I and aVL. (B) Repeat electrocardiogram at our facility demonstrating similar findings. (C) Computed tomography showing hepatosplenomegaly with subtle peripancreatic inflammatory stranding (findings later corroborated by magnetic resonance cholangiopancreatography).

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  Figure 2. Lipemic Blood Sample of the Patient Compared With a Normal Sample, Demonstrating a Creamy Supernatant After Centrifugation

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  Figure 3. Three-Generation Pedigree of the Patient's Family Squares indicate males and circles indicate females. The proband is represented by a filled symbol. Deceased individuals are marked with a diagonal slash. Clinical details, including laboratory values and relevant history, are provided within the figure. HDL = high-density lipoprotein; LDL = low-density lipoprotein; TC = total cholesterol; TG = triglycerides; VLDL = very-low-density lipoprotein.

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  Figure 4. Coronary Angiography of the Patient Arrows indicate key findings. (A and B) RAO caudal and RAO cranial views, respectively, showing critical stenosis of the mid LAD. (C) Deployment of a DES in the LAD. (D and E) Post-procedural images demonstrating TIMI flow grade 3 in the LAD. DES = drug-eluting stent; LAD = left anterior descending artery; RAO = right anterior oblique.

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  Figure 5. Phenotypic Framework for Dyslipidemia Based on Predominant Lipid Elevation Dyslipidemia is initially categorized by the predominant lipid abnormality (cholesterol, mixed, or triglyceride-predominant). Triglyceride-predominant disorders are further contextualized within the severe hypertriglyceridemia spectrum, in which type IV and type V represent overlapping phenotypes within the triglyceride-rich lipoprotein spectrum. The index case is positioned within this framework based on biochemical and clinical features, alongside highlighted elements contributing to diagnostic uncertainty. apoB = apolipoprotein B; CM = chylomicron; FCHL = familial combined hyperlipidemia; FCS = familial chylomicronemia syndrome; FDBL = familial dysbetalipoproteinemia; FH = familial hypercholesterolemia; FHTG = familial hypertriglyceridemia; HTG = hypertriglyceridemia; IDL = intermediate-density lipoprotein; MCS = multifactorial chylomicronemia syndrome; N = normal; sHTG = severe hypertriglyceridemia; other abbreviations as in Figure 3.

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  Figure 6. Lipemia-Induced Analytical Interference This figure summarizes laboratory values affected in lipemia, highlighting affected assays, underlying analytical mechanisms, resultant spurious results, and strategies to confirm analytical interference rather than true pathology. ABG = arterial blood gas; INR = international normalized ratio; ISE = ion-selective electrode; PT = prothrombin time.