Hyperlipidemia with polyarthritis
A 42-year-old diabetic female presented with multiple joint pain (small and large joints) associated with swelling over wrists, hands, and ankles. The first episode of pain in wrist joints (onset 3 months), was minimal without any special characteristic features. The patient developed second episode of polyarthritis involving almost all small and large joints following fever, probably viral. The febrile illness lasted for 1 week and was associated with generalized arthralgias and myalgia without any rash/eruption, jaundice, lymphadenopathy, enteritis, or respiratory/urogenital tract infections. The duration between febrile illness and second episode of arthritis was one and half months. The joint pain started in wrists and small joints of hands, and later affected large joints along with swelling in wrists, hands, and ankles. Joint pain was additive and incapacitating, lasting throughout the day. The total duration of the pain was around 15 days before presenting to the outpatient facility. She was taking glimepiride twice daily and denied any back pain, thyroid, dermatological, urogenital or eye problem.
The most likely diagnosis of this presentation is
Hyperlipidemia can give rise to various musculoskeletal disorders (MSK) such as acute polyarthritis or even simple arthralgias.1-3 Literature search reveals that MSK manifestations are mostly observed in familial cases of hyperlipoproteinemia, especially in pediatric cases.
She underwent hysterectomy 2 years earlier (oophorectomy status unknown) and was diabetic since 10 years. There was no family history of connective tissue disease or premature death.
Examination and Laboratory Investigations
Her musculoskeletal examination revealed inflamed and swollen wrists, ankle, and metacarpophalangeal (MCP) joints. Tenderness on palpation and movement (active & passive) of large joints were noted. Enthesitis in the form of tendoachilis tenderness was present. The serum sample was very lipemic and fasting lipid profile was also carried out along with other relevant clinical investigations. X-ray of hands indicated mild juxta-articular osteoporosis.
She was diagnosed with hyperlipidemia with polyarthritis. The patient was prescribed with a single dose methylprednisolone 160 mg injection on her first day visit. Daily dose of anti-lipid medications (atorvastatin 10 mg with fenofibrate 160 mg) and nonsteroidal anti-inflammatory drugs (NSAIDS) on need basis were also administered. The 2 months of treatment contributed to disease improvement and resolution of joint pain and swelling.
Presence of high triglycerides and total cholesterol, along with low LDL and HDL in lipid profiling confirmed the disease as hyperlipidemia. As the patient did not have obesity, hypertension or thyroid disease, so hyperlipidemia seems to be secondary or acquired, possibly due to (i) the patient being middle aged, diabetic with poor diabetic control, (ii) there was no family history of any premature atherosclerotic event. The patient responded well to anti-lipid therapy with resolution of arthritis and normalization of inflammatory parameters. Diabetes mellitus is commonly encountered as a cause of secondary dyslipoproteinemia. Other conditions leading to acquired hyperlipidemia include hypothyroidism, renal failure, nephrotic syndrome, alcohol use, and drugs such as diuretics, beta blockers, and estrogens.2,3 It has already been established that systemic inflammation can be a notable contributor of lipid profile changes.4 Conversely, evidence indicates that lipids can have a direct modulating effect on inflammation. For example, hypercholesterolemia induces inflammation by increasing circulating inflammatory cells. 5,6
Febrile Illness could have triggered an inflammatory episode, which was subsequently potentiated by hyperlipidemia, or already existing hyperlipidemia could have triggered an enhanced inflammatory response.
- Rondier J, Cayla J, Roux H, Turpin G. [Hyperlipemias and their manifestations in the rheumatological sphere]. Sem Hop. 1977 Apr 9;53(14-15):813–22
- Chait A, Brunzell JD. Acquired hyperlipidemia (secondary dyslipoproteinemias). Endocrinol Metab Clin North Am. 1990 Jun;19(2):259–78
- Pejic RN, Lee DT. Hypertriglyceridemia. J Am Board Fam Med. 2006 Jun;19(3):310–6
- Myasoedova E, Crowson CS, Kremers HM, et al. Lipid paradox in rheumatoid arthritis: the impact of serum lipid measures and systemic inflammation on the risk of cardiovascular disease. Ann Rheum Dis. 2011 Mar;70(3):482–7
- Drechsler M, Megens RTA, van Zandvoort M, et al. Hyperlipidemia-triggered neutrophilia promotes early atherosclerosis. Circulation. 2010 Nov 2;122(18):1837–45
- Swirski FK, Libby P, Aikawa E, et al. Ly-6Chi monocytes dominate hypercholesterolemia-associated monocytosis and give rise to macrophages in atheromata. J Clin Invest. 2007 Jan;117(1):195–205