Low HDL-Cholesterol & Lymphoma
Several months ago, a cardiologist asked what could cause an HDL to decrease from his patient’s usual 50 to 5 mg/dl, besides lab error. The person also has new anemia. I gave the differential below including the production of antibodies against HDL by myeloma and some lymphomas. The cardiologist recently called to tell me that his patient turned out to have diffuse large B-cell lymphoma, activated B-cell subtype. I emailed about this, but for those who did not get the email, here is my differential of a newly low HDL.
1. Atorvastatin can reduce HDL. It really does not cause HDL to plummet, but in contrast to all the other statins, there is a decrease in average HDL when you go from 40 to 80 mg/dl a day, and some people can actually get a marked decrease. I did not think that was the issue with this particular patient since the low HDL appeared while the patient was already on atorvastatin.
2. Oral anabolic steroids produce big, rapid decreases in HDL. Injectable testosterone does not probably because the oral stuff goes into the portal circulation and undergoes first pass metabolism in the liver. We reported this oral vs injectable anabolic steroid effect in 1989 in our report comparing stanozolol (the oral drug Ben Johnson used at the 1988 Olympics) and testosterone.(1)
3. Monoclonal antibodies produced by myeloma like conditions and lymphomas can decrease HDL. You should at least let that run through your mind because you can find these things early. This is especially true in your patient with the anemia. You may be detecting early myeloma.
4. The combination of fenofibrate and glitizones can do this. We reported several cases. (2}
5. I think copper supplements can do this but have never evaluated this further. HDL is measured as cholesterol after the apo B containing lipoproteins are precipitated with the divalent cation, Manganese. I have wondered if other divalent cations, like Cu+2 can do it. I have had 2 patients in 40 years who increased their very low HDL after we stopped their Cu supplements. This is just a WAI (wild ass idea) so don’t bank on it. I did a pubmed search, but found no reports of Cu doing this
Here is a graph of the change in HDL in our stanozolol study. Measurements were baseline, 1, 2, 4 & 6 weeks. Most of the decrease occurred right away. The HDL is in mMol, but the baseline was about 44 mg/dl.
1. Thompson PD, Cullinane EM, Sady SP, et al. Contrasting effects of testosterone and stanozolol on serum lipoprotein levels. JAMA. 1989;261(8):1165–1168.
2. Venero CV, Thompson PD, Fernandez AB. Reduced high-density lipoprotein cholesterol in patients receiving rosiglitazone and fenofibrate. Am J Med. 2008;121(10):e3–4. doi: 10.1016/j.amjmed.2008.06.019 [doi].
