Detection of Neovascularization in Achilles Tendon Xanthoma With Familial Hypercholesterolemia

A 64-year-old woman presented to Minamino Cardiovascular Hospital with chest pain and electrocardiography evidence of ST-segment elevation in leads V1 to V4. She was diagnosed with myocardial infarction and underwent percutaneous coronary intervention. Despite lipid-lowering therapy, her low-density lipoprotein cholesterol concentration at presentation was elevated (165 mg/dL). Familial hypercholesterolemia (FH) was suspected, and the Achilles tendons were evaluated using non-contrast computed tomography (CT) and ultrasound. CT revealed bilateral thickening of the Achilles tendons (right 7.8 mm, left 8.0 mm) consistent with Achilles tendon xanthomas (ATX). Arterial blood vessels were observed in the fat around the Achilles tendon and the fat had an increased CT number, suggesting inflammation (Figure A–C; Supplementary Figure). Doppler ultrasound demonstrated arterial blood flow within the ATX (Figure D,E). The patient was diagnosed with FH based on the diagnostic criteria.¹ Treatment with proprotein convertase subtilisin/kexin type 9 inhibitors was initiated. ATX is one of the typical features of FH, and it has been reported that lipids accumulate in the extracellular matrix of tendons, potentially affecting their mechanical properties.² Therefore, neovascularization is associated with chronic inflammation, which may play an important role in the deposition of cholesterol crystals leading to ATX. The findings of this report may contribute to an early diagnosis of FH.

Figure.

(A) Axial and (B) sagittal computed tomography (CT) images of the Achilles tendon show microvessels in the fat anterior to the Achilles tendon, and an increased CT number in the fat (arrowheads). (C) Vessels are also depicted in the fat in the volume rendering image of the Achilles tendon. (D,E) Microvessels in the short-axis view of the ultrasound are identified as arterial blood from the power Doppler waveform.

Acknowledgments / Sources of Funding / Disclosures / IRB Information

None.

Supplementary Files

Please find supplementary file(s);

https://doi.org/10.1253/circrep.CR-24-0120

References

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• 2.   Yang Y, Lu H, Qu J. Tendon pathology in hypercholesterolaemia patients: Epidemiology, pathogenesis and management. J Orthop Translat 2019; 16: 14–22.