Severe Hypertriglyceridemia in Critically Ill Patients with COVID-19

Introduction: COVID-19 has a wide range of clinical manifestations involving multiple organ systems. There have been a few cases in the literature that demonstrate the association between COVID-19 and hypertriglyceridemia in the setting of treatment with tocilizumab. We report, to our knowledge, the first known series of patients with critical illness resulting from COVID-19, who developed severe hypertriglyceridemia in the absence of treatment with tocilizumab. Description: Case 1: A 57-year-old male with end-stage renal disease, diabetes mellitus, and hypertension was admitted to the hospital with worsening shortness of breath due to COVID-19. He was initially managed with conservative measures including supplemental oxygen on the medical floor but required transfer to the ICU for worsening hypoxemia necessitating invasive mechanical ventilation. The patient developed a lipemic serum on hospital day 8. His triglyceride level was noted to be 3160mg/dl, with a baseline level of 224mg/dl 1-year prior. Patient deteriorated rapidly and expired before appropriate treatment measures for his hypertriglyceridemia could be implemented. Case 2: A 73-year-old male with pulmonary fibrosis and coronary artery disease was admitted to the hospital with shortness of breath due to COVID-19. He was managed with remdesivir and dexamethasone on the medical floor, but deteriorated further and required invasive mechanical ventilation and continuous renal replacement therapy. Patient developed lipemic serum on hospital day 19 and was found to have a triglyceride level of 1757mg/dl, with a baseline level of 173mg/dl 1-year prior. Patient was started on an insulin infusion but continued to deteriorate and expired on hospital day 20. Case 3: A 47-year-old hypertensive male patient was admitted with worsening shortness of breath due to COVID-19. He was initially treated with dexamethasone and supplemental oxygen but deteriorated and required invasive mechanical ventilation as well as continuous renal replacement therapy. He was noted to have a lipemic serum on hospital day 14 and was found to have a triglyceride level of 945mg/dl. Patient was managed with an insulin infusion with subsequent improvement in his levels. Patient had a prolonged hospitalization and required tracheostomy but has since made a full recovery including the recovery of his renal function, and has returned to work. Image below shows the lipemic serum of our patient: Discussion: These cases suggest an association between severe COVID-19 and hypertriglyceridemia in the absence of treatment with tocilizumab. Further studies are needed to determine whether this association truly exists, its implications on prognosis, and to determine optimal management strategies.