Successful treatment of steroid-resistant Weber–Christian disease with biliary ductopenia using cyclosporin A

Intravenous Immune Globulin (IVIG) Therapy After Unsuccessful Treatment with Corticosteroid and Cyclosporine A in Pfeifer-Weber-Christian Disease: A Case Report

BACKGROUND Pfeifer-Weber-Christian disease (PWCD), also referred to as idiopathic nodular panniculitis, is a rare idiopathic disease characterized by lobular panniculitis of adipose tissue with systemic symptoms and multiple organ involvement and is usually treated with corticosteroids and cyclosporine A. We report a case of PWCD that was unresponsive to standard treatment but responded to intravenous immune globulin (IVIG) therapy. CASE REPORT A 35-year-old Korean woman presented with fever, malaise, myalgia, and painful nodules in the left breast. Histology of the breast nodules showed lobular panniculitis consistent with PWCD. She did not respond to corticosteroid and cyclosporine A. She was effectively treated with intravenous immune globulin (IVIG). IVIG therapy began with 60 g (1 g/kg) 4 times per week, 2 times every other week. Subsequently, the IVIG dose was reduced for maintenance therapy to 25 g (400 mg/kg) twice every other week and monthly. The patient showed immediate and dramatic improvement. General signs and symptoms, such as fever, malaise, and myalgia, were absent, and the masses had nearly subsided, with several very small hard nodules remaining for 3 months until the time of this report. CONCLUSIONS IVIG was an effective immunomodulatory therapeutic for PWCD in this case. This report shows that PWCD is a rare condition that is difficult to diagnose, but the histopathology of nodular panniculitis supports the diagnosis. In cases that do not respond to standard immunosuppressive therapy, including corticosteroids and cyclosporine A, IVIG therapy may lead to a favorable response with rapid symptomatic relief.

[Idiopatic Lobular Panniculitis as a common clinical problem]

AIM

To present clinical and laboratory characteristics of various forms of idiopatic lobular panniculitis (ILP) in modern rheumatology practice.

MATERIALS AND METHODS

The study included 67 people (58 women and 9 men aged 20 to 76) with the referral diagnosis of "Erythema nodosa? Undifferentiated panniculitis?" in 76.2% of cases with a median disease duration of 78.91 [48; 540] months observed in the V.A. Nasonova Research Institute of Rheumatology. In 2007-2017 in addition to general clinical examination immunological, histological and immunohistochemical studies, computed tomography (CT) of the chest organs and tuberculin tests were performed.

RESULTS

Analysis of clinical manifestations allowed to distinguish four forms of ILP: nodular (n=30), plaque (n=10), infiltrative (n=15) and mesentric (n=12). The minimum median duration of the disease was detected in plaque form (8 [5; 11.5] months), while the median duration in case of infitrative form was 8.25 times longer (66 [36; 102] months, p38 °C and a small number (up to 5) of drain nodes; infiltrative - fever >38 °C, ulceration of nodes with the expiration of oily mass and scarring; mesenteric - pain in the abdominal area, the number of nodes less than 5 and the abdominal cavity CT results (inflammation of the adiopose tissue of the intestinal mesentery, omentum, adipose tissue of the pre - and retroperitoneal areas).

CONCLUSION

The forms and activity of the disease determine the approaches to treatment in modern clinical practice. There is an obvious need to expand knowledge about this pathology among doctors and conduct further research in order to timely diagnose and search for the most effective methods of ILP treatment.

Recurrent panniculitis: Weber-Christian disease

Weber-Christian disease is characterized by recurrent inflammation in the fat layer of the skin. We report a boy, aged 2 years and 9 months, with Weber-Christian disease who presented with tender rounded swelling on the dorsum of both hands and chest wall with mild erythema in overlying skin associated with high grade continuous fever.

Ocular Inflammation: Can It Be a Sign of Activity of Weber-Christian Disease? A Case Report and Review of Literature

PURPOSE

To present a case of Weber-Christian disease with symptomatic ocular involvment. Weber-Christian disease is a relapsing febrile nodular nonsuppurative panniculitis. It is characterized by malaise and fever accompanied by subcutaneous inflammatory nodules on the trunk and extremities. It can affect several organs, but ocular signs have been infrequently described in literature.

METHODS

A 20-year-old woman with Weber-Christian disease presented with severe bilateral ocular inflammation. A complete ophthalmologic examination was performed.

RESULTS

Visual acuity was 20/100 in both eyes and slit-lamp examination showed bilateral iridocyclitis. Bilateral cortico-nuclear cataract did not allow funduscopy and she underwent cataract extraction. Retinal vasculitis was detected.

CONCLUSIONS

Patients with Weber-Christian disease can develop severe ocular inflammation. A complete ophthalmolgic examination should be done in these patients, especially when ocular involvement is the main sign of the disease. A further understanding of the severity of ocular inflammation proved fundamental in the management of the disease.

Weber-Christian disease developing into mediastinitis and pleuritis with massive pleural effusion

A 53-year-old man visited our hospital complaining of high fever. Chest computed tomography showed left pleural effusion and mediastinitis. He developed painful red subcutaneous nodules in his bilateral lower extremities. Thoracoscopy-assisted exploratory excision showed visceral pleura thickening; panniculitis in the periaortic area was histologically proven. The patient was treated with corticosteroid therapy which immediately reduced the fever. Subsequent imaging examinations after corticosteroid therapy showed improvement of mediastinitis and pleural effusion. This case reminds us that Weber-Christian disease (WCD) should be included in the differential diagnosis of mediastinitis although WCD is rarely associated with thoracic involvement.

Lobular panniculitis with small vessel vasculitis associated with ulcerative colitis

We report a rare case of lobular panniculitis with small vessel vasculitis, presenting with fever, cutaneous lesions, and systemic manifestations involving the visceral fat and associated with ulcerative colitis. The patient was treated with cyclophosphamide and prednisolone, which successfully cured the systemic disease, with resolution of the inflammatory infiltrates.

Long-Term Evolution of Cytophagic Histiocytic Panniculitis

Background:

Cytophagic histiocytic panniculitis is a disorder manifested by multiple subcutaneous nodules, characterized by lobular panniculitis, and occasionally accompanied by severe systemic manifestations, which require an aggressive medical approach. Several case reports with a good response to immunosuppressive therapy in the acute phase can be found in the literature.

Objective and Conclusion:

Nevertheless, the long-term evolution of this entity has not been described yet, nor have precise recommendations regarding the most adequate posology and duration of therapy. We report the result of switching from a long-term cyclosporine therapy to tacrolimus in a patient with a severe form of cytophagic histiocytic panniculitis.

A patient with Pfeifer-Weber-Christian disease--successful therapy with cyclosporin A: case report

BACKGROUND

Pfeifer-Weber-Christian disease (PWCD) is a rare inflammatory disorder of the subcutaneous fatty tissue. The diagnosis and therapy of this rare type of panniculitis is still controversial and will be discussed in this article.

CASE PRESENTATION

We here report the rare case of a 64-year old male patient, with PWCD. The patient suffered from rheumatoid arthritis for several years, but then developed relapsing fever and recently occurring painful subcutaneous nodules predominantly at the inner part of his left upper limb with no signs of synovitis. Finally, a biopsy from one of the nodules revealed lobular panniculitis with mixed cell infiltrate, which was conformable only with PWCD, after excluding several differential diagnoses. In our patient PWCD developed despite immunosuppressive therapy with steroids and different disease modifying drugs, which the patient received to treat his underlying rheumatoid arthritis. However, when DMARD therapy was switched to Ciclosporin A the patient's symptoms resolved.

CONCLUSION

Our observation supports the hypothesis that T cells are involved in the pathogenesis of PWCD. Thus, T cell modifying drugs should be primarily used to treat patients with this rare disorder.

Childhood Weber-Christian disease: clinical investigation and virus detection

OBJECTIVE

To investigate clinical features of childhood Weber-Christian disease (WCD) and the relationship between WCD and virus.

METHODS

The clinical characteristics, laboratory findings, therapy and clinical course of nine patients were reviewed and the viral antigens (EBV, CMV, HSV1 and HSV2) were detected.

RESULTS

They were six males and three females with a median age of 9 years. They included four simple and five systemic WCD, and all presented fever and tender subcutaneous nodules. Other clinical features included hepatomegaly in nine patients, splenomegaly in two, lymphadenhypertrophy in six, respiratory system involved in two, gastrointestinal tract involved in two and convulsion and bleeding in one. Anaemia was noted in seven patients, raised ALT in three, hypergammaglobulnaemia in three, proteinuria in one and three of six patients positive of antinuclear antibodies (ANA). No viral antigens were found. Corticosteroids therapy was administrated for all patients, immunoglobulin for two, non-steroidal anti-inflammatory agents for three and cyclophosphamide for one. Five patients released after therapy and three patients died.

CONCLUSIONS

WCD is a severe disease characterized by relapsing, febrile subcutaneous nodules and biopsy is needed for early diagnosis. The viral infection may not be associated with WCD.

Weber–Christian disease presenting with intractable fever and periorbital swelling mimicking angioedema

A 22-year-old male patient with Weber-Christian disease (WCD) presenting with periorbital swelling is a very rare occurrence. Lobular panniculitis in the periorbital and anterior tibial skin was diagnosed in this patient, based on the histological findings from biopsy specimens. The differential diagnosis was done before administering systemic corticosteroid. A dramatic response was achieved several days later, but relapse with intractable fever occurred 1 month later. The use of other immunosuppressive agents failed, and he died of septic shock 2 months later. The preceding infection may have been the immunopathologic factor in the development of WCD. Other effective treatments for WCD may be described in the future.