Clinical Chemistry 61:12
1441–1445 (2015)
Six-Month-Old Boy with “Milky” Serum
Sarah K. Anisowicz1* and Jude M. Abadie2
CASE DESCRIPTION
At his 6-month well baby visit, a male infant was noted to
have splenomegaly without any other notable physical
examination findings. His medical history was unre-
markable. He was born at term by elective repeat Cesar-
ean section, with normal growth and development. A
screening complete blood count and comprehensive met-
abolic panel were ordered, but laboratory testing could
not be performed due to grossly lipemic samples (Fig. 1).
At that point, the patient was referred to pediatric gastro-
enterology owing to splenomegaly with subsequent li-
pemic samples.
Physical examination by pediatric gastroenterology
at 7 months described a large infant with weight in the
99th percentile (10.4 kg), 81st percentile for length (71
cm), and 70th percentile for head circumference (44.5
cm). Body mass index was in the 99th percentile. Growth
charts indicated that he was born at the 60th percentile
for weight and increased to the 99th percentile at 6
months. Since the time of birth, length and head circum-
ference demonstrated a stable growth rate at 80th and
57th to 70th percentiles, respectively. Multiple lipomas
on his left ear lobe, lateral canthus of the right eye, abdo-
men, and back were noted on examination. Abdominal
examination showed a nondistended, soft, nontender ab-
domen with splenomegaly 2 cm below the lower costal
margin. Hepatomegaly was absent, and no other abdom-
inal masses were appreciated.
Family history was remarkable for a maternal grand-
mother who was diagnosed with hypertriglyceridemia
and hypercholesterolemia discovered during an episode
of pancreatitis. Triglycerides were reportedly “in the
thousands” before treatment was initiated.
Abdominal ultrasound was notable for splenomeg-
aly of 3.4 by 8.3 cm (upper reference limit 6.5 cm). The
complete blood count listed in Table 1 suggested anemia
and demonstrated a white blood cell count within refer-
1
Department of Pediatrics and 2 Department of Pathology, Tripler Army Medical Center,
Honolulu, HI.
* Address correspondence to this author at: Tripler Army Medical Center, 1 Jarrett White Road,
MCHK-PE, Honolulu, HI 96859. Fax 808-433-4837; e-mail sarah.k.anisowicz.mil@mail.mil.
Disclaimer: The views expressed in this case study are those of the authors and do not
reflect the official policy of the Department of the Army, the Department of Defense, or the
United States Government.
Received October 27, 2014; accepted April 7, 2015.
DOI: 10.1373/clinchem.2014.235143
姝 2015 American Association for Clinical Chemistry
Clinical Case Study
QUESTIONS TO CONSIDER
1. What laboratory markers help to navigate and guide
a differential diagnosis in patients presenting with
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splenomegaly?
2. How can lipemia affect laboratory test results?
ence intervals. Coagulation panel, fibrinogen, lipase, uric
acid, and thyroid studies were all within reference inter-
vals. The lipid panel demonstrated increased total cho-
lesterol and triglycerides, with LDL within reference in-
tervals and low HDL. VLDL concentrations could not be
calculated because of the markedly increased triglycer-
ides. ␣-1-Fetoprotein was within reference intervals for
the patient’s age (1 ).
Lipoprotein phenotyping demonstrated increased
triglycerides (661 mg/dL), low total cholesterol (85 mg/
dL), low HDL cholesterol (5 mg/dL), and presence of
chylomicrons with ␣ and ␤ band within reference inter-
vals and increased pre-␤ band. VLDL and LDL were not
calculated because of increased triglycerides. These re-
sults were indicative of type IV familial hyperlipidemia
(isolated hypertriglyceridemia), and the patient was pre-
scribed dietary fish oil supplementation. The patient’s
parents underwent phenotyping screening as well, with
the mother showing a normal lipid profile and the father
a similar hypertriglyceridemia.
DISCUSSION
An infant with splenomegaly is of concern for a broad
differential, including hemolytic anemia, portal hyper-
tension, malignancy, hemophagocytic lymphohistiocy-
tosis, and glycogen storage disorders. Laboratory testing
ruled out these conditions, with white blood cell count,
iron studies, ␣-1-fetoprotein (1 ), and uric acid within
reference intervals (Table 1). Despite the presence of ane-
mia, a bilirubin concentration within reference intervals
showed no evidence of hemolysis. Xanthomas were noted
on examination, and laboratory evaluation demonstrated
grossly lipemic serum, which narrowed the differential to
a lipid disorder.
In children, increased triglyceride concentrations are
often secondary to conditions such as obesity and type 2
diabetes mellitus. However, familial hyperlipidemia is an
important consideration when a patient presents at such
1441
Clinical Case Study

Table 1. Initial laboratory evaluation.

Reference
Assay Resulta interval
White blood cell count, 16.6 6–17.5
× 103/mL
Hemoglobin, g/dL 8.4 (L) 10.5–13.0
Hematocrit, % 28.4 (L) 34–40
Partial thromboplastin time, s 39 35.1–46.3
Prothrombin time, s 13.3 11.5–15.3

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International normalized ratio 1.0 0.86–1.22
Fibrinogen, g/L 3.62 0.82–8.83
Iron, μmol/L 39.2 7.2–44.8
Transferrin, g/dL 2.89 2.03–3.6
Iron binding capacity, μmol/L 64.6 17.9–71.6
Ferritin, pmol/L 322 16–615
Uric acid, mmol/L 0.178 0.065–0.33
Total bilirubin, mg/dL 0.7 <1.2
Thyroid stimulating hormone, 2.25 0.35–5.0
mIU/L
Fig. 1. Patient’s blood after centrifugation.
Free thyroxine, ng/dL 1.18 0.8–1.6
Lipase, U/L 58 8–78
Cholesterol, mg/dL 277 (H) <170
HDL cholesterol, mg/dL <6 (L) >35
a young age. Before lipids were used in conjunction with
LDL cholesterol, mg/dL 83 <110
National Cholesterol Education Program guidelines to
Triglycerides, mg/dL 831 (H) <150
predict coronary disease, the Fredrickson classification
␣-1-Fetoprotein, ng/dL 87.0 8–87
(FC) was mainly used to characterize lipid disorders (2 ).
The FC correlated electrophoresis results to clinical dis- a
H and L indicate high or low values compared with the reference interval.
ease syndromes and laboratory phenotypes (3 ). Each of
the phenotypes was related to a variety of disorders affect-
ing the same lipoprotein and demonstrating the same glyceridemia is fat-induced and is caused by the inability
lipid pattern. Treatment did not vary within the same to break down chylomicrons. This produces a more pro-
phenotype. Although it was developed ⬎40 years ago, nounced chylomicron band on electrophoresis and a
the FC continues to be used when categorizing lipid pa- large layer of chylomicrons in the centrifuged sample.
thognomonic syndromes. Applying FC to our case supported a diagnosis of
Characterization of the FC uses multiple diagnostic type IV hyperlipidemia, an endogenous hypertriglyceri-
criteria, including serum lipid concentrations, appear- demia marked by highly increased triglycerides and
ance of centrifuged serum, and lipoprotein electrophore- within reference intervals to slightly increased choles-
sis. To assess the serum, the refrigerator test consists of terol. The FC describes type IV as having a negative
cooling the sample overnight at 4 °C and evaluating the refrigerator test and an increased pre-␤ band on electro-
sample for a chylomicron layer (creamy layer) on top of phoresis. As illustrated in Fig. 1, the patient’s plasma had
the sample, then identifying the infranate as clear (type I) a cloudy appearance, which differed from clear plasma
or turbid (type IV). Electrophoresis separates by size, associated with types I and IIa. This presentation of a
with each band representing a different lipoprotein. The sample in the laboratory is due to hyperprebetalipopro-
band migrating closest to the cathode is the ␣ band, teinemia (VLDL), whereas LDL is usually within refer-
consisting of HDL. Pre-␤ bands appear more proximally ence intervals; thus, electrophoresis produces a more
than HDL and represent VLDL. ␤-Bands are located prominent pre-␤ band. The phenotype classification per-
between the chylomicrons at the origin and the pre-␤ formed at LabCorp reported a turbid appearance, with
region, representing LDL. the presence of chylomicrons, and an increased pre-␤
The FC allows for differentiation of endogenous vs band. Per the FC, chylomicrons do not define type IV
exogenous hypertriglyceridemia. Endogenous hypertri- hyperlipidemia; therefore, in this patient (Fig. 1), their
glyceridemia, also known as carbohydrate-induced, in- presence may be the result of a postprandial sample.
creases the triglyceride concentration by increased VLDL Familial hypertriglyceridemia is associated with lipo-
production. These diseases have a more prominent pre-␤ protein patterns presenting in conjunction with familial hy-
band on electrophoresis. In contrast, exogenous hypertri- perlipidemia syndromes. Cases of type IV hyperlipidemia

1442 Clinical Chemistry 61:12 (2015)


are often autosomal dominant, affecting 1:300 people in the
US (4 ). This disorder is identified mainly in adults with
fasting triglycerides ⱕ500 mg/dL and is less frequently rec-
ognized in infants. The patient’s father had the same lipid
profile, supporting an autosomal dominant inheritance. Ge-
netic testing was not performed on this patient since it
would not change management. Although complete patho-
physiology mechanisms for this lipid dysregulation have not
been elucidated, it has been demonstrated that VLDL tri-
glyceride production is increased in the setting of normal
apolipoprotein B synthesis. This leads to the formation of
triglyceride-laden VLDL molecules that explain the “milky”
appearance in the tube.
Children with familial hypertriglyceridemia are of-
ten asymptomatic, but can present with colicky pain or
failure to thrive. Examination of this patient revealed
splenomegaly and xanthomas. Lipemic serum may be
another presenting indicator and has been reported in 2
other case reports of infants with hypertriglyceridemia.
One patient displayed hepatomegaly and lipemia retina-
lis (5 ), and another presented with hepatosplenomegaly,
lipemia retinalis, and xanthomas (6 ). A 1983 report of
children with familial hypertriglyceridemia noted ab-
dominal pain, limb or scrotum swelling, and xanthoma
eruption during times of increased plasma triglyceride
concentrations (7 ). Aside from increased triglycerides,
laboratory testing can indicate anemia, thought to be due
to alterations of erythrocyte membranes (5 ). Signifi-
cantly increased triglyceride concentrations also prevent
the measurement of VLDL and LDL in lipid panels.
In adults, increased triglyceride concentrations are
known to cause endothelial dysfunction and can acceler-
ate the formation of atherosclerotic plaques, leading to
coronary artery disease. As in our patient’s family history,
markedly increased triglyceride concentrations can pre-
cipitate pancreatitis.
Treatment of patients with hypertriglyceridemia be-
gins with lifestyle modifications of diet and exercise, ir-
respective of etiology. Our patient has continued with a
formula diet, and as he ages the main dietary component
will be low-fat foods. At 1 year of age, the standard rec-
ommendation is to transition from formula to whole
milk; however, this patient will instead drink nonfat milk
in an effort to promote a low-fat diet. He will be followed
annually to monitor his lipid profile.
His diet has been supplemented with fish oil to reduce
triglyceride concentrations. A recent randomized, double-
blind study showed reduction of triglyceride concentrations
in adolescents on fish oil, but the results were not statistically
significant compared with the placebo group (8 ). In older
children, fibrates have been shown to be an effective option
to reduce triglyceride concentrations (9 ).
Clinical Case Study
POINTS TO REMEMBER
• Splenomegaly is a physical examination finding of con-
cern for glycogen storage disorder, malignancy, portal
hypertension, and hyperlipidemia. Laboratory evalua-
tion for these disorders should include a complete blood
count, lipid panel, and abdominal ultrasound.
• The FC is used to characterize lipid disorders by corre-
lating electrophoresis results to clinical disease syn-
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dromes and laboratory phenotypes.
• Type IV hyperlipidemia is notable for increased triglyc-
erides with relatively normal cholesterol concentrations.
Type IV is distinguished as having a negative refriger-
ator test and an increased pre-␤ band on electropho-
resis, with the plasma appearing cloudy.
• Patients with familial hypertriglyceridemia may be
asymptomatic or may present with failure to thrive and
colic. Physical examination may be unremarkable or
could note hepatosplenomegaly or xanthomas.
Author Contributions: All authors confirmed they have contributed to
the intellectual content of this paper and have met the following 3 require-
ments: (a) significant contributions to the conception and design, acquisi-
tion of data, or analysis and interpretation of data; (b) drafting or revising
the article for intellectual content; and (c) final approval of the published
article.
Authors’ Disclosures or Potential Conflicts of Interest: No authors
declared any potential conflicts of interest.
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Clinical Chemistry 61:12 (2015) 1443