Death by Triglycerides: A Multifaceted Case of Dyslipidemia, Obesity, and PMOS Resulting In Lethal Acute Pancreatitis

A 23-year-old female was found unresponsive after 3 weeks of illness and presented to urgent care a day before her death with a complaint of nausea, vomiting, and abdominal cramping. She had a history of obesity and polyendocrine metabolic ovarian syndrome (PMOS). At autopsy, nonhemorrhagic acute pancreatitis and steatohepatitis were identified. During the exam, areas of fat congealing within pooled blood were noted. Tubes of blood drawn during the examination became grossly lipemic at room temperature. Toxicological and laboratory testing showed a triglyceride level of 5440 mg/dL, HDL 9 mg/dL, total cholesterol 740 mg/dL, 0.06% wt/vol acetone in peripheral blood, and therapeutic levels of fluconazole. Postmortem genetic testing revealed an LDLR mutation associated with familial hypercholesterolemia. Obesity, high cholesterol, and PMOS are all disturbances known to perpetuate further metabolic issues, including severe hypertriglyceridemia (HTG). Most causes of severe HTG are the result of multigenic or polygenic mutations and are further exacerbated by exposure to nongenetic secondary factors. The combination of the patient's familial dyslipidemia, PMOS, and obesity created a compounding effect of metabolic dysfunction leading to her sudden death. Overall, this case highlights the need for close follow-up in patients with these conditions and better education on the possible consequences of their interplay, which can prove lethal.