The glucagonoma syndrome

Necrolytic Migratory Erythema: Case Report and Clinical Review

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.

Endocrine pancreatic tumors with glucagon hypersecretion: a retrospective study of 23 cases during 20 years

BACKGROUND

Glucagon-secreting endocrine pancreatic tumor is a rare disease, hence controlled studies on clinical management are lacking. In an attempt to assess the efficacy of diagnostic and therapeutic measures in patients with glucagonoma, a retrospective study was performed using the archives of a tertiary care center.

PATIENTS AND METHODS

Records from 340 patients with endocrine pancreatic tumors were reassessed and 23 patients with malignant endocrine pancreatic tumor and elevated plasma glucagon levels were identified.

RESULTS

About 7% of patients with histologically verified tumors fullfilled our criteria for glucagonoma. Only 22% of these patients had developed diabetes prior to the diagnosis of glucagonoma. Seventy eight percent had metastatic disease to the liver at diagnosis. Necrolytic migratory erythema was diagnosed or clinically suspected in 52%. Somatostatin receptor scintigraphy was positive in 95%. Nineteen patients received chemotherapy at some point, in 18 cases streptozotocin and 5 FU. With this treatment, objective radiological responses were seen in 50% of evaluable patients. Other treatment modalities used were interferon, somatostatin analogs, hepatic artery embolization, radio-frequency ablation of liver metastases, and radiolabeled somatostatin analogs. During the study period, 11 patients died at a median of 80 months from diagnosis whereas 11 patients are still alive after a median follow up of 52 months. One patient was lost to follow-up.

CONCLUSIONS

Glucagonomas represent 7% of our comprehensive referral material of endocrine pancreatic tumors. Necrolytic migratory erythema was a common finding (52%) and diabetes less frequent at presentation than previously reported. Tumors were positive on somatostatin receptor scintigraphy and objective responses were seen to chemotherapy.

The glucagonoma syndrome: a review of its features and discussion of new perspectives

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.

The glucagonoma syndrome. Clinical and pathologic features in 21 patients

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.

Necrolytic migratory erythema: a report of three cases

Necrolytic migratory erythema (NME) is a cutaneous reaction pattern with specific histopathologic features that is typically associated with a functioning pancreatic islet cell neoplasm such as a glucagonoma. Three examples of NME, each associated with a different cause, are presented: glucagonoma, pancreatic insufficiency, and gluten-sensitive enteropathy. All three patients were successfully treated by surgical resection of the pancreatic tumor, total parenteral nutrition and pancreatic enzyme replacement, or a strict gluten-free diet, respectively. All remain free of skin disease more than 2 years later. Any patient with NME should be evaluated for glucagonoma and small bowel disease that may be associated with malabsorption and malnutrition.

Necrolytic migratory erythema without glucagonoma versus canine superficial necrolytic dermatitis: is hepatic impairment a clue to pathogenesis?

The case of a 57-year-old diabetic man with necrolytic migratory erythema in the absence of glucagonoma is reported. The clinical and pathologic features of his dermatitis and subsequent clinical course are compared with those of canine superficial necrolytic dermatitis, an unusual cutaneous necrotizing eruption of dogs that is identical histologically to necrolytic migratory erythema. In addition to a necrolytic dermatitis, both our patient and most dogs with superficial necrolytic dermatitis have diabetes mellitus and hepatic failure in the absence of glucagonoma. Thus hyperglucagonemia most likely is not a factor in the origin of the necrotizing dermatitis in this patient or in dogs. The role of hepatocellular dysfunction in the pathogenesis of necrolytic migratory erythema and superficial necrolytic dermatitis is considered.

Necrolytic migratory erythema: dyskeratotic dermatitis, a clue to early diagnosis

A 57-year-old woman with a 6-year history of a dermatitis that evolved into typical necrolytic migratory erythema is reported. Four biopsy specimens were obtained in 5 years. The early lesions revealed superficial perivascular inflammation in the dermis, minor epidermal spongiosis, and scattered dyskeratotic cells in the upper epidermis. The differential diagnosis of this pattern of dyskeratotic dermatitis, particularly in a chronic eruption, should include consideration of hyperglucagonemia and the possibility of an associated pancreatic islet cell tumor.

Nutritional deficiency and the skin

Cutaneous changes occur in deficiency states of many nutritional elements: ascorbic acid, retinol, protein-energy, cyanocobalamin, phytonadione (vitamin K), biotin, ribroflavin, pyridoxine, niacin, essential fatty acids, and zinc. There are also inherited disorders of copper, biotin, zinc, and tryptophan metabolism. Cutaneous vitamin D synthesis is inhibited by sunscreen use. The striking skin changes of the glucagonoma syndrome may be related to nutritional pathways.

Successful treatment of glucagonoma-related necrolytic migratory erythema with dacarbazine

A 63-year-old man with a glucagonoma syndrome is described. The diagnosis was confirmed by necrolytic migratory erythema, which is the most distinctive feature of the clinical syndrome. There was no chance of operative resection of the tumor because of liver metastases at the time of diagnosis. The patient was treated with dacarbazine. During this treatment the skin lesions disappeared completely.

Glucagonoma syndrome. A clinicopathologic, immunocytochemical, and ultrastructural study

Necrolytic migratory erythema has been considered to be a paraneoplastic dermatosis. Although some individuals have had no associated neoplasm, a pancreatic glucagonoma is typically found in the vast majority. We describe a 71-year-old woman with findings strongly suggestive of the glucagonoma syndrome. The plasma glucagon level was modestly elevated. Special studies of the pancreas, including computerized axial tomography and selective angiography, did not demonstrate a tumor. Surgery, however, revealed a 5-cm tumor in the head of the pancreas. Although immunocytochemical stains showed only rare, weakly reactive cells, the electron microscopic study confirmed the diagnosis of an islet cell tumor and revealed characteristic morphologic features of glucagonoma.

Glucagonoma syndrome: case report and literature review

The glucagonoma syndrome is characterized by dermatitis, glucose intolerance, hypoaminoacidemia, and hyperglucagonemia secondary to an alpha-cell tumor of the pancreas. Other clinical features include anemia, glossitis, and weight loss. A 62-year-old woman with the syndrome sought medical attention for a chronic dermatitis. A skin biopsy was suggestive of necrolytic migratory erythema. A glucagonoma was surgically removed from the tail of the pancreas. Review of the literature indicates that 56 proven and 33 probable cases of glucagonoma syndrome have been reported.

Alopecia and periorificial dermatitis in biotin-responsive multiple carboxylase deficiency

Three siblings with infantile-onset biotin-responsive multiple carboxylase deficiency are described. Recognition of the characteristic dermatologic manifestations, alopecia and periorificial dermatitis, should result in early diagnosis and institution of potentially lifesaving therapy with biotin. Other metabolic disorders may present a similar clinical picture. Immunologic dysfunction and/or aberration in lipid or branched chain amino acid metabolism may be the common pathophysiologic link in some or all of these disorders.