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Abstract
Background: Necrolytic Migratory Erythema (NME) is a rarely encountered dermatologic condition. It is the characteristic feature of a paraneoplastic syndrome associated with neuroendocrine pancreatic tumors. A case of NME initially diagnosed and treated as psoriasis is reviewed. A review of the current literature regarding NME is also included. Objective: The purpose of this report is to familiarize dermatologists with a rare and potentially fatal disorder. Early recognition of NME can lead to possible cure, while delayed identification of the disease is associated with metastatic disease and a poor prognosis for the patient. Conclusion: When evaluating the patient who presents with a dermatitis and weight loss, it is important to exercise great caution. The differential diagnosis should be reevaluated in a disease that is not responsive to first-line therapy before further treatment is considered.
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Affiliation(s)
- David N Adam
- Department of Medicine, University of Toronto, Ontario, Canada.
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Shah KR, Boland CR, Patel M, Thrash B, Menter A. Cutaneous manifestations of gastrointestinal disease. J Am Acad Dermatol 2013; 68:189.e1-21; quiz 210. [DOI: 10.1016/j.jaad.2012.10.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 10/11/2012] [Accepted: 10/13/2012] [Indexed: 01/13/2023]
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Lobo I, Carvalho A, Amaral C, Machado S, Carvalho R. Glucagonoma syndrome and necrolytic migratory erythema. Int J Dermatol 2010; 49:24-9. [DOI: 10.1111/j.1365-4632.2009.04220.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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BEWLEY A, ROSS J, BUNKER C, STAUGHTON R. Successful treatment of a patient with octreotide-resistant necrolytic migratory erythema. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1996.d01-910.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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7
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Gadgeel SM, Wozniak AJ. Paraneoplastic Syndromes. Oncology 2007. [DOI: 10.1007/0-387-31056-8_85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Cutaneous paraneoplastic syndromes are a group of noncancerous dermatoses associated with internal malignancy. Their recognition can facilitate detection and timely treatment of underlying cancer. More than 30 such disorders have been identified in the human scientific literature, whereas only a few are described in veterinary medicine. This may reflect a lower incidence in animals than in people or may be the result of failure to recognize an association between certain skin lesions and neoplasia. Establishing a relationship between a cutaneous disorder and neoplasia can be difficult unless the skin lesions are rare and almost always associated with a particular tumour type, as is the case for most recognized veterinary paraneoplastic dermatoses. Among these are feline paraneoplastic alopecia, feline thymoma-associated exfoliative dermatitis, nodular dermatofibrosis, feminization syndrome associated with testicular tumours, superficial necrolytic dermatitis and paraneoplastic pemphigus. The aetiology of most cutaneous paraneoplastic syndromes has remained elusive in both people and animals.
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Affiliation(s)
- Michelle M Turek
- School of Veterinary Medicine, Department of Surgical Sciences, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, USA.
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Pujol RM, Wang CYE, el-Azhary RA, Su WPD, Gibson LE, Schroeter AL. Necrolytic migratory erythema: clinicopathologic study of 13 cases. Int J Dermatol 2004; 43:12-8. [PMID: 14693015 DOI: 10.1111/j.1365-4632.2004.01844.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The clinical mucocutaneous manifestations of glucagonoma syndrome are recognized easily when they occur in the classic pattern of acral or periorificial lesions evolving in recurrent crops, with an annular and migratory distribution, in a patient with diabetes mellitus who has had recent weight loss and anemia. Not infrequently, noncharacteristic clinical and histopathologic features are observed and, in these cases, the diagnosis of pancreatic neoplasm may be delayed. AIM To review the clinical and histopathologic features of cutaneous manifestations of glucagonoma syndrome. METHODS The clinicopathologic features of 13 patients (eight women) with widespread or localized cutaneous eruption as a manifestation of islet cell pancreatic carcinoma with marked glucagon secretion (glucagonoma) were reviewed. RESULTS The definitive diagnosis of the cutaneous eruption was established at the time of diagnosis of the pancreatic neoplasm (three patients) or afterwards (10 patients). In nine patients, the mucocutaneous manifestations preceded the diagnosis of the pancreatic neoplasm by 1 month to 3 years (mean, 12 months). In only eight biopsy specimens were the histopathologic features considered to be suggestive or characteristic of necrolytic migratory erythema. Diffuse parakeratosis, that occasionally arose abruptly from normal epidermis, was observed in 12 biopsy specimens. By the time necrolytic migratory erythema was diagnosed, the pancreatic carcinoma had metastasized to the liver, regional lymph nodes, or bone in 12 patients. CONCLUSION Increased awareness of the polymorphic mucocutaneous and nonspecific histopathologic features of glucagonoma syndrome is needed to avoid unnecessary delay in the diagnosis of this syndrome.
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Affiliation(s)
- Ramon M Pujol
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Johnson SM, Smoller BR, Lamps LW, Horn TD. Necrolytic migratory erythema as the only presenting sign of a glucagonoma. J Am Acad Dermatol 2003; 49:325-8. [PMID: 12894090 DOI: 10.1067/s0190-9622(02)61774-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We describe a 39-year-old man with a 3-year history of a recalcitrant psoriasiform eruption that was accentuated in the intertriginous areas. Hsitopathology was consistent with psoriasis. A glucagon level was 744 pg/mL with the upper limit of normal being 130 pg/mL. Computed tomographic scan of the abdomen revealed a 5-cm mass in the tail of the pancreas. The tumor was removed and found to be a glucagonoma (pancreatic islet tumor). The clinical eruption resolved promptly with surgical excision. Neither the clinical eruption nor the tumor has recurred for 6 months. The course of disease confirms the diagnosis of necrolytic migratory erythema associated with a glucagonoma.
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Affiliation(s)
- Sandra Marchese Johnson
- Departments of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.
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Case CC, Vassilopoulou-Sellin R. Reproduction of features of the glucagonoma syndrome with continuous intravenous glucagon infusion as therapy for tumor-induced hypoglycemia. Endocr Pract 2003; 9:22-5. [PMID: 12917088 DOI: 10.4158/ep.9.1.22] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To describe the adverse effects of continuous intravenous infusion of glucagon as therapy for tumor-induced hypoglycemia and to correlate these treatment-related effects with symptoms of endogenous hyper-glucagonemia. METHODS We reviewed three cases in which patients received continuous glucagon therapy for tumor-induced hypoglycemia and experienced adverse side effects to the treatment. We noted that these adverse events were consistent with changes that are described in the literature as symptoms of the glucagonoma syndrome. RESULTS Continuous intravenous glucagon infusion has evolved as a reliable and efficacious modality for the treatment of tumor-induced hypoglycemia. We report the adverse events of venous thromboembolism, necrolytic migratory erythema, and angular cheilitis in conjunction with continuous intravenous glucagon treatment. These complications resemble symptoms that characterize the human model of hyperglucagonemia--the glucagonoma syndrome--which is associated with hyperglucagonemia and alpha-islet cell neoplasms of the pancreas. CONCLUSION Symptoms that characterize the islet cell neoplasm-related glucagonoma syndrome may develop in patients receiving an infusion of exogenous glucagon. This observation lends support to the suggestion that glucagon may have a direct, causative role.
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Affiliation(s)
- Christopher C Case
- Division of Endocrinology and Metabolism, Baylor College of Medicine, Houston, Texas, USA
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Alexander EK, Robinson M, Staniec M, Dluhy RG. Peripheral amino acid and fatty acid infusion for the treatment of necrolytic migratory erythema in the glucagonoma syndrome. Clin Endocrinol (Oxf) 2002; 57:827-31. [PMID: 12460334 DOI: 10.1046/j.1365-2265.2002.01660.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Necrolytic migratory erythema (NME), the characteristic rash associated with the glucagonoma syndrome, is a cause of substantial morbidity among patients with this rare malignancy. Treatment options are suboptimal, and often useful for only short or moderate durations. We report the effective, long-term (> 1 year) use of intermittent infusions of amino acids (AA) and fatty acids (FA) administered via peripheral intravenous access for the treatment of NME in the glucagonoma syndrome. Despite resolution of the NME, serum amino acid (initially subnormal) and fatty acid (initially normal) levels remained unchanged. Tumour growth and other symptoms related to the glucagonoma syndrome appear unaffected by such infusions.
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Affiliation(s)
- Erik K Alexander
- Thyroid and Endocrine Divisions, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachussets, USA.
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Abstract
Skin manifestations of systemic disease and malignancy are protean. The recognition of a potentially paraneoplastic dermatosis as such must prompt an investigation for occult malignancy. Lack of familiarity with cutaneous clues of internal malignancy may delay diagnosis and treatment of cancer. It is important to consider a paraneoplastic process in the differential diagnosis of a number of eruptive and treatment-resistant dermatoses. These dermatoses may be the first sign of an occult neoplasm. Their recognition may assist in cancer detection and the swift induction of appropriate therapy.
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Affiliation(s)
- Sarah Boyce
- Department of Dermatology, University of Alabama at Birmingham, EFH, Suite 414, Birmingham, AL 35294, USA
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Dal Coleto CC, de Mello AP, Piquero-Casals J, Lima FR, Vilela MA, Festa-Neto C, Sanches JA. Necrolytic migratory erythema associated with glucagonoma syndrome: a case report. REVISTA DO HOSPITAL DAS CLINICAS 2001; 56:183-8. [PMID: 11836542 DOI: 10.1590/s0041-87812001000600005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Necrolytic migratory erythema is a rare skin condition that consists of migrating areas of erythema with blisters that heal with hyperpigmentation. It usually occurs in patients with an alpha islet cell tumor of the pancreas-or glucagonoma-and when associated with glucose intolerance, anemia, hyperglucagonemia, and weight loss defines the glucagonoma syndrome. We describe a 52-year-old female patient with necrolytic migratory erythema associated with glucagonoma syndrome who had metastatic disease at presentation and passed away one week after her admission. The autopsy showed a tumor in the body of the pancreas, which was diagnosed as a neuroendocrine tumor and confirmed by immunohistochemistry. The diagnosis of necrolytic migratory erythema is a matter of great importance, since it might be an auxiliary tool for the early detection of glucagonoma.
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Affiliation(s)
- C C Dal Coleto
- Department of Dermatology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Brazil
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Abstract
Glucagonoma syndrome is a paraneoplastic phenomenon characterized by an islet alpha-cell pancreatic tumor, necrolytic migratory erythema, diabetes mellitus, weight loss, anemia, stomatitis, thromboembolism, and gastrointestinal and neuropsychiatric disturbances. These clinical findings in association with hyperglucagonemia and demonstrable pancreatic tumor establish the diagnosis. Glucagon itself is responsible for most of the observed signs and symptoms, and its induction of hypoaminoacidemia is thought to lead to necrolytic migratory erythema. Liver disease and fatty acid and zinc deficiency states may also contribute to the pathogenesis of the eruption in some cases. Most patients are diagnosed too late in the clinical course for cure, but successful palliation of symptomatology can usually be achieved with surgical and medical intervention. This paper reviews the glucagonoma syndrome, paying particular attention to its cutaneous features, and provides new perspectives in our current understanding of this phenomenon.
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Affiliation(s)
- M A Chastain
- Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
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César Blázquez Encinar J, Jimeno Sainz A, Orti Tarazona C, de Teresa Parreño L. Eritema migratorio necrolítico como manifestación inicial de glucagonoma normoglucémico. Med Clin (Barc) 2001. [DOI: 10.1016/s0025-7753(01)72047-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Godfrey DR, Rest JR. Suspected necrolytic migratory erythema associated with chronic hepatopathy in a cat. J Small Anim Pract 2000; 41:324-8. [PMID: 10976630 DOI: 10.1111/j.1748-5827.2000.tb03211.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A cat presenting with generalised hypotrichosis and crusts on the feet and tail was found to have an unusual chronic hepatopathy. There was also evidence of a chronic small intestinal disease which went undiagnosed. Necrolytic migratory erythema was suspected based on clinical findings and dermatohistopathology, and an association with the chronic hepatopathy was suggested. This is the first report of such an association in a cat. Serum zinc, amino acids and essential fatty acids were analysed, and medical treatment was given with equivocal efficacy.
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Affiliation(s)
- D R Godfrey
- Nine Lives Veterinary Practice for Cats, Hockley Heath, West Midlands
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Alkemade JA, van Tongeren JH, van Haelst UJ, Smals A, Steijlen PM, van de Kerkhof PC. Delayed diagnosis of glucagonoma syndrome. Clin Exp Dermatol 1999; 24:455-7. [PMID: 10606947 DOI: 10.1046/j.1365-2230.1999.00531.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The classical presentations of necrolytic migratory erythema associated with alpha cell pancreatic tumour have been well documented. In addition, the occurrence of extracutaneous hallmarks of this disease such as weight loss, diabetes, anaemia, stomatitis and diarrhoea have been described in various reports. Here we report three cases with glucagonoma syndrome. Early detection is important in view of the malignant course of the disease. However, diagnosis is sometimes complicated by the fact that some patients may fail to show the characteristic feature of glucagonoma syndrome.
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Affiliation(s)
- J A Alkemade
- Department of Dermatology, University Hospital Nijmegen St Radboud, The Netherlands.
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Mullans EA, Cohen PR. Iatrogenic necrolytic migratory erythema: a case report and review of nonglucagonoma-associated necrolytic migratory erythema. J Am Acad Dermatol 1998; 38:866-73. [PMID: 9591806 DOI: 10.1016/s0190-9622(98)70478-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Necrolytic migratory erythema is characterized by waves of irregular erythema in which a central bulla develops, and subsequently erodes and becomes crusted. It usually occurs in patients with an alpha-islet cell tumor of the pancreas. However, necrolytic migratory erythema has also been observed in patients without an associated glucagonoma. We describe a woman with iatrogenic necrolytic migratory erythema. She received intravenous glucagon for hypoglycemia associated with an insulin-like growth factor II-secreting hemangiopericytoma. After chemotherapy, she developed necrolytic migratory erythema. The characteristics of the previously reported patients with nonglucagonoma-associated necrolytic migratory erythema are reviewed. In patients with nonglucagonoma-associated necrolytic migratory erythema, the dermatosis-related conditions most commonly observed were celiac disease or malabsorption, cirrhosis, malignancy, and pancreatitis; less common conditions included hepatitis, inflammatory bowel disease, heroin abuse, and odontogenic abscess. Although the pathogenesis of necrolytic migratory erythema remains unknown, hyperglucagonemia appears to have had a causative role in the development of this dermatosis in our patient. Patients who develop necrolytic migratory erythema should be evaluated for the presence of a glucagonoma; if a glucagonoma is ruled out, evaluation for other conditions known to occur with necrolytic migratory erythema, such as liver disease, malabsorptive disorders, and nonislet-cell tumors is warranted.
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Affiliation(s)
- E A Mullans
- Department of Dermatology, University of Texas-Houston Medical School, 77030, USA
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Torres S, Johnson K, McKeever P, Hardy R. Superficial necrolytic dermatitis and a pancreatic endocrine tumour in a dog. J Small Anim Pract 1997; 38:246-50. [PMID: 9200114 DOI: 10.1111/j.1748-5827.1997.tb03358.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A 13-year-old dog was referred for a severe dermatological problem of 12 months duration. Skin biopsy results were compatible with superficial necrolytic dermatitis. The only laboratory abnormalities were hyperglycaemia and hyperglucagonaemia. These findings suggested a pancreatic endocrine tumour in association with superficial necrolytic dermatitis. Abdominal ultrasound examination was unremarkable. The dog was euthanased due to the lack of clinical improvement following symptomatic therapy. Postmortem examination revealed a pancreatic endocrine tumour with liver metastases. Pancreatic endocrine tumour cells were immunoreactive for glucagon, insulin and islet amyloid polypeptide.
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Affiliation(s)
- S Torres
- Department of Small Animal Clinical Sciences, University of Minnesota, St Paul 55108, USA
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BEWLEY A, ROSS J, BUNKER C, STAUGHTON R. Successful treatment of a patient with octreotide–resistant necrolytic migratory erythema. Br J Dermatol 1996. [DOI: 10.1111/j.1365-2133.1996.tb07951.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
A 55-year-old man presented with an 11-year history of necrolytic migratory erythema and glossitis. After the patient's serum glucagon was demonstrated to be elevated, computed tomography scan revealed a mass involving the head of the pancreas. The patient underwent a Whipple-type pancreatico-duodenectomy and his rash resolved completely 6 days after tumor resection. He received no adjuvant treatment. A discussion of the varying theories regarding the pathogenesis and treatment of glucagon-associated necrolytic migratory erythema is presented.
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Affiliation(s)
- A P Smith
- Department of General Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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Wermers RA, Fatourechi V, Wynne AG, Kvols LK, Lloyd RV. The glucagonoma syndrome. Clinical and pathologic features in 21 patients. Medicine (Baltimore) 1996; 75:53-63. [PMID: 8606627 DOI: 10.1097/00005792-199603000-00002] [Citation(s) in RCA: 223] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The glucagonoma syndrome is a rare disorder characterized by weight loss, necrolytic migratory erythema (NME), diabetes, stomatitis, and diarrhea. We identified 21 patients with the glucagonoma syndrome evaluated at the Mayo Clinic from 1975 to 1991. Although NME and diabetes help identify patients with glucagonomas, other manifestations of malignant disease often lead to the diagnosis. If the diagnosis is made after the tumor is metastatic, the potential for cure is limited. The most common presenting symptoms of the glucagonoma syndrome were weight loss (71%), NME (67%), diabetes mellitus (38%), cheilosis or stomatitis (29%), and diarrhea (29%). Although only 8 of the 21 patients had diabetes at presentation, diabetes eventually developed in 16 patients, 75% of whom required insulin therapy. Symptoms other than NME or diabetes mellitus led to the diagnosis of an islet cell tumor in 7 patients. The combination of NME and diabetes mellitus led to a more rapid diagnosis (7 months) than either symptom alone (4 years). Ten patients had diabetes mellitus before the onset of NME. No patients had NME clearly preceding diabetes mellitus. Increased levels of secondary hormones, such as gastrin (4 patients), vasoactive intestinal peptide (1 patient), serotonin (5 patients), insulin (6 patients, clinically significant in 1 only), human pancreatic polypeptide (2 patients), calcitonin (2 patients) and adrenocorticotropic hormone (2 patients), contributed to clinical symptoms leading to the diagnosis of an islet cell tumor before the onset of the full glucagonoma syndrome in 2 patients. All patients had metastatic disease at presentation. Surgical debulking, chemotherapy, somatostatin, and hepatic artery embolization offered palliation of NME, diabetes, weight loss, and diarrhea. Despite the malignant potential of the glucagonomas, only 9 of 21 patients had tumor-related deaths, occurring an average of 4.91 years after diagnosis. Twelve patients were still alive, with an average age follow-up of 3.67 years.
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Affiliation(s)
- R A Wermers
- Division of Endocrinology/Metabolism and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Affiliation(s)
- K D Rappaport
- Mayo Graduate School of Medicine, Mayo Clinic Jacksonville, Florida 32224, USA
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Marinkovich MP, Botella R, Datloff J, Sangueza OP. Necrolytic migratory erythema without glucagonoma in patients with liver disease. J Am Acad Dermatol 1995; 32:604-9. [PMID: 7896950 DOI: 10.1016/0190-9622(95)90345-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Necrolytic migratory erythema (NME) is an uncommon inflammatory dermatosis with a distinct clinical and histologic appearance. NME is usually associated with glucagonoma. Only a few cases of NME in the absence of glucagonoma have been previously reported. OBJECTIVE We sought to understand further the pathogenesis of NME by analyzing data from three patients. METHODS Three patients were examined both clinically and histopathologically. RESULTS Each patient had an extensive erythematous scaling eruption in intertriginous, perioral, and acral areas, and a markedly red, smooth tongue. Skin biopsy specimens showed confluent parakeratosis, epidermal pallor, papillary edema, and a lymphohistiocytic infiltrate. Two patients had alcoholic liver disease and one had liver dysfunction as a result of hemochromatosis. Serum albumin level was depressed, and liver enzyme values were increased in all three patients. Glucagonoma was undetectable in these patients. CONCLUSION In the absence of glucagonoma, hepatocellular dysfunction and hypoalbuminemia appear to be the most common factors associated with NME.
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Affiliation(s)
- M P Marinkovich
- Department of Dermatology, Oregon Health Sciences University, Portland
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