A 4 year-old male patient was referred to our institution by a dermatologist because of the gradually increasing number of xanthomas on the knees, elbows, and buttocks that first appeared when he was 3 years old. He was born after an uneventful pregnancy and delivery as the second child of apparently non-consanguineous parents. The family history for premature CVD was negative. His early development was normal. Extremely high levels of TC (24.8 mmol/L; 928 mg/dl), LDL-C (21.6 mmol/L; 834 mg/dl), and triglycerides (TGC) (5.0 mmol/L; 443 mg/dl) and low levels of HDL-cholesterol (HDL-C) (0.3 mmol/L; 11.6 mg/dl) were measured at the first exam. Elevated levels of TC and LDL-C were also found in his parents, sister, and daughter (afterward) (). The clinical and biochemical picture suggested the diagnosis of HoFH, which was later confirmed genetically; a previously described homozygous mutation c.1754T>C (p.Ile585Thr) was found in the patient, while both his parents, his sister, and daughter were confirmed to be heterozygotes for the same mutation. Despite treatment with a highly restrictive diet, cholestyramine, statins, and LDL-apheresis (the exact timeline is described in , ), xanthomas extended progressively. At 7 years, increased IMT of the common carotid artery was measured with ultrasound. At 12 years, echocardiographically valvular aortic stenosis and aortic regurgitation were observed. Levels of LDL-C at the time of LDL-apheresis ranged from 2.4 to 11.6 mmol/L (92.8–449 mg/dl) in between treatments. Lp(a) levels ranged from 756 mg/L at the beginning to 135 mg/L after the last treatment. He refused to have apheresis for 3 years, but with psychological support, he continued.\nDue to progressive worsening conditions (valvular aortic stenosis and aortic regurgitation), the patient underwent deceased-donor orthotopic LT when he was 16 years old. There were no intraoperative or postoperative complications. The patient's immunosuppression regimen first consisted of tacrolimus, methylprednisolone, and ursodeoxycholic acid, but the steroid was gradually tapered. Six months after the LT, the patient's xanthomas had regressed, and the TC levels have fallen to 5.2 mmol/L (201 mg/dl). A year and a half after the LT, the TC level was at the lowest value [4.4 mmol/L (170 mg/dl)]. Two years after the LT, an episode of acute rejection developed, which was successfully treated with steroids, and the TC level was measured at 5.1 mmol/L (197 mg/dl).\nEight years after the LT, the patient who was then 24 years old was doing well. The patient had been on maintaining tacrolimus therapy. His cutaneous xanthomas completely resolved. An echocardiogram showed complete regression of aortic stenosis, and his IMT was in the normal range (0.6 mm on both common carotid arteries). His TC and LDL-C levels were 5.4 and 3.9 mmol/L, respectively (209 and 151 mg/dl), and Lp(a) levels were 111 mg/L. His LDL-C levels were lower than the LDL-C levels measured on the same occasion in his parents and sister (). Twelve years after the LT, the PWV velocity was measured with ultrasound, and the values were in the normal range (4.6 ± 0.2 m/s) The RHI was 2.46.\nAfterward, the patient was not responding to the invitations from our clinic for almost 5 years (at that time, he was only seeing his gastroenterologist) and returned for a follow-up visit only in the year 2018, almost 14 years after the LT. The total regression of xanthomas was evident at the last visit. At that point, he was almost 30 years old, employed, and had a child who was scheduled for a later visit at our lipid clinic and was confirmed to be heterozygote for the same mutation. His work was mostly sedentary, and he was not very physically active. In addition, he started smoking. He was still taking tacrolimus, but no antilipemic treatment was prescribed to him after the LT. His TC and LDL-C levels were 7.2 mmol/L (278 mg/dl) and 5.3 mmol/L (205 mg/dl), respectively. In addition, an elevated ApoB level was present (1.48 g/L), while his Lp(a) level was normal (145 mg/L). Furthermore, hsCRP was 2.11 mg/L. His carotid IMT level had increased to 0.90 mm on both carotid arteries (abnormal result for his age) (). He was normotensive (97/67 mmHg), and his BMI was 18 kg/m2. Liver enzyme levels were in the normal range. The HbA1c level was 4.8%, and the fasting insulin level was 4.3 mE/L. The glomerular filtration rate was above 90 ml/min. At the last visit to our lipid clinic, the patient was recommended to start statin treatment (rosuvastatin, 10 mg) and was transitioned to the adult lipid clinic, where his first visit was scheduled in early 2019. At that visit, his TC and LDL-C levels were 7.36 mmol/L (284.6 mg/dl) and 5.9 mmol/L (228.15 mg/dl), respectively.
A 37-year-old lady presented to us with subacute onset progressive ataxia, with tendency to sway toward the left, of 2 month duration. She had significant weight loss, anorexia, and recurrent fevers for 6 months. She was emaciated, had oral candidiasis, and hepatomegaly. Neurological examination revealed left gaze evoked nystagmus, incoordination involving the left extremities, and slurred speech. HIV serology done was positive with a CD4 count of 28/μL. Cerebrospinal fluid study revealed normal opening pressure, mild elevation of protein (65 mg%) with no cells and normal glucose.\nMRI of the brain multiplanar T1, T2, FLAIR, diffusion and postcontrast done on a 1.5 Tesla system (Avanto-SQ Engine, Siemens Medical Systems, Erlanger, Germany) revealed the classical HCB sign in pons. In addition, there were asymmetrical T2 hyperintense lesions involving the left middle and inferior cerebellar peducle extending into left cerebellar hemisphere with atrophy of the same structures []. The left cerebellar hemispheric hyperintensities were partially suppressible on FLAIR and not enhancing on contrast []. Magnetic resonance spectroscopy revealed reduction of N-Acetylaspartic acid peak with mild elevation of choline. Imaging features suggested a possible necrotic demyelinating process asymmetrically, involving the left cerebellar white matter and transverse pontine fibers consistent with PML.