Photo Quiz

White, Opaque Fluid in a Blood Draw

Am Fam Physician. 2009 Apr 15;79(8):699-700.

A 44-year-old woman presented to the clinic to establish care. She had a history of hyperlipidemia, type 2 diabetes, childhood polio, and diabetic retinopathy. She had no medical complaints, but admitted that no laboratory testing had been performed recently. At the time of her visit, the patient was fasting. She said that she did not check her blood glucose, exercise, or follow a diabetic diet. A review of her systems was negative, and her vitals were normal. Physical examination revealed obesity, weakness in her right leg secondary to childhood polio, and acanthosis nigricans. Routine laboratory tests were ordered, including complete blood count, comprehensive metabolic panel, lipid level, and urine microalbumin:creatinine ratio. Her blood draw produced white, opaque fluid (see accompanying figure).

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Cryoglobulinemia.

B. Hodgkin lymphoma.

C. Hypertriglyceridemia.

D. Pancreatitis.

E. Sepsis.

Discussion

The answer is C: hypertriglyceridemia. White, opaque serum, along with a history of poorly controlled diabetes and hyperlipidemia, is consistent with severe hypertriglyceridemia. The patient's laboratory results confirmed the diagnosis. Severe hypertriglyceridemia (triglyceride levels greater than 500 mg per dL [5.65 mmol per L])1 may manifest as a grossly lipemic serum sample when levels exceed 1,000 mg per dL (11.30 mmol per L).

The treatment goals for elevated triglyceride levels depend on severity. Usually, the primary goal is to achieve a target low-density lipoprotein (LDL) level that is based on the patient's risk stratification. Dietary modification and weight reduction are recommended for borderline-high triglyceride levels (150 to 199 mg per dL [1.70 to 2.25 mmol per L]). However, when triglyceride levels are high (200 to 499 mg per dL [2.26 to 5.64 mmol per L]), non–high-density lipoprotein cholesterol should be the secondary target of therapy. When triglyceride levels are very high (greater than 500 mg per dL), the primary goal is lowering the triglyceride level to minimize the risk of acute pancreatitis. Recommendations to accomplish this goal include a very low-fat diet (15 percent of total caloric intake), weight reduction, increased physical activity, and pharmacotherapy (e.g., fibrates, nicotinic acid). After triglyceride levels are reduced to less than 500 mg per dL, the focus of treatment returns to LDL reduction to lower the risk of heart disease. Although a combination of statins and fibrates can be used, the risk of myopathy and rhabdomyolysis increases with combination therapy.2 Fenofibrate (Tricor) has a lower risk of myopathy than gemfibrozil (Lopid).2

Cryoglobulinemia is the presence of cryoglobulins in the serum, which leads to a systemic inflammatory syndrome caused by cryoglobulin-containing immune complexes. To confirm the diagnosis, a blood sample must be collected in a warm tube without anticoagulants. The sample should clot before removing the serum via centrifugation. The subtypes of cryoglobulinemia vary in concentration and length of time for precipitation. Cryoglobulinemia does not cause lipemic serum.

Hodgkin lymphoma is a malignancy of lymphatic tissue. Reed-Sternberg cells are present in a background of reactive leukocytes or fibrosis.3 Patients with lymphoma and a triglyceride level greater than 200 mg per dL may develop chylous ascites (milky white ascitic fluid), a rare but well-reported complication.4 However, these patients do not have white, opaque serum.

Pancreatitis is an inflammatory and life-threatening condition that may be caused by gallstones, alcoholism, medications, elevated triglyceride levels, or malignancy. Pancreatitis manifests as multiple systemic and metabolic findings and is generally treated with supportive measures. Acute pancreatitis may cause chylous ascites.5 Pancreatitis with severe hypertriglyceridemia can lead to lipemia.

With sepsis, a systemic infection is followed by a systemic inf lammatory response. Typically, patients are febrile, hypotensive, tachycardic, and tachypneic. Treatment involves hemodynamic support, especially fluid resuscitation; antimicrobials; and other therapies, based on the patient's condition. White, opaque serum is not consistent with sepsis unless hypertriglyceridemia is also present.

Summary Table

Condition Characteristics

Cryoglobulinemia

Presence of cryoglobulins in serum, leading to an inflammatory response; not associated with white, opaque serum

Hodgkin lymphoma

Malignancy of lymphatic tissue; patients with coexisting hypertriglyceridemia may have chylous ascites

Severe hypertriglyceridemia

Elevated triglyceride level (generally greater than 500 mg per dL [5.65 mmol per L]) required fordiagnosis of severe hypertriglyceridemia; lipemic serum may be present with levels greater than 1,000 mg per dL (11.30 mmol per L)

Pancreatitis

Inflammatory condition caused by gallstones, alcoholism, medications, elevated triglyceride levels, or malignancy; may lead to chylous ascites; patients with coexisting hypertriglyceridemia may have lipemic serum

Sepsis

Systemic infection and inflammatory response; does not cause white, opaque serum unless hypertriglyceridemia is also present

Summary Table

View Table

Summary Table

Condition Characteristics

Cryoglobulinemia

Presence of cryoglobulins in serum, leading to an inflammatory response; not associated with white, opaque serum

Hodgkin lymphoma

Malignancy of lymphatic tissue; patients with coexisting hypertriglyceridemia may have chylous ascites

Severe hypertriglyceridemia

Elevated triglyceride level (generally greater than 500 mg per dL [5.65 mmol per L]) required fordiagnosis of severe hypertriglyceridemia; lipemic serum may be present with levels greater than 1,000 mg per dL (11.30 mmol per L)

Pancreatitis

Inflammatory condition caused by gallstones, alcoholism, medications, elevated triglyceride levels, or malignancy; may lead to chylous ascites; patients with coexisting hypertriglyceridemia may have lipemic serum

Sepsis

Systemic infection and inflammatory response; does not cause white, opaque serum unless hypertriglyceridemia is also present

Address correspondence to Anush S. Pillai, DO, FAAFP, at aspillai@tmhs.org. Reprints are not available from the author.

Author disclosure: Nothing to disclose.

REFERENCES

1. National Institutes of Health. Third report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Executive Summary http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3xsum.pdf. Accessed June 18, 2007.

2. Oh RC, Lanier JB. Management of hypertriglyceridemia. Am Fam Physician. 2007;75(9):1365–1371.

3. Yung L, Linch D. Hodgkin's lymphoma. Lancet. 2003;361(9361):943–951.

4. Antonarakis ES, Fradin JM, Petronis JD, Couzi RJ. Not what it seems. Am J Med. 2007;120(5):408–411.

5. Khan FY, Matar I. Chylous ascites secondary to hyperlipidemic pancreatitis with normal serum amylase and lipase. World J Gastroenterol. 2007;13(3):480–482.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.


Copyright © 2009 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article