2 | CASE HISTORY/EXAMINATION
A 35-year-old Chinese man was admitted to Kurume University Hospital on May, 2020 owing to fatigue and hyperglycemia. He stated that hyperlipidemia and hyperglycemia started 2 years prior but that he discontinued any treatment. He had neither any familial history of dyslipidemia and diabetes mellitus nor a life history of drug, alcohol, or smoking abuse. On examination, his body mass index and abdominal circumference were 32 kg/m² and 106.1 cm, respectively. Multiple clustered papules were observed on the bilateral extremities (Figure 1). Histopathological examinations of skin biopsy specimens led to the diagnosis of eruptive xanthomas (Figure 2). Laboratory examinations demonstrated high levels of fasting serum triglyceride (1871 mg/dL) and total cholesterol (371 mg/dL) and low levels of high-density lipoprotein cholesterol (22 mg/dL). However, low-density lipoprotein (LDL) cholesterol levels were within the normal range. Examination of lipoprotein fraction showed that the mid-band and small-dense LDL was contained (Figure 3). Chronic hyperglycemia was also denoted, with a fasting plasma glucose level of 203 mg/dL and HbA1c value (NGSP) of 9.9% (Table 1). Other examinations, including electrocardiogram and chest radiograph, were unremarkable. Ultrasonography revealed moderate to severe fatty liver (Figure 4). Diet therapy with 1600 kcal/day calorie restriction and 0.2 mg/day of pemafibrate, which was ultimately increased to 0.4 mg/day orally, were initiated to reduce serum lipids. Additionally, 500 mg/day of metformin and 10 mg/day of empagliflozin were administrated to improve insulin sensitivity and hyperglycemia. Finally, both serum triglyceride and plasma glucose levels improved to 425 and 101 mg/dL, respectively, with a concomitant change in color of the skin lesions from red to white and a decrease in the number of eruptions until total eradication.