Panniculitis in childhood

Lupus Panniculitis with Combined Features of Dermatomyositis Resulting in Severe Lipoatrophy

An 11-year-old girl presented with a one-year history of multiple, hard, slightly painful subcutaneous nodules on her right cheek, upper arms, and buttock. Histology of a skin biopsy specimen showed a lobular panniculitis. Laboratory studies revealed positive ANA, anti-double strand DNA, and elevated muscle enzymes. She was diagnosed as having lupus panniculitis. During hydroxychloroquine treatment, erythema over knuckle joints developed. These unusual clinical and laboratory findings of panniculitis associated connective tissue diseases made it difficult to make a precise diagnosis. We report this unusual case of lupus panniculitis with combined features of dermatomyositis resulting in severe lipoatrophy.

Idiopathic nodular panniculitis in Niemann-Pick disease

Idiopathic nodular panniculitis is a condition characterized by the recurrent appearance of inflammatory nodules in the subcutaneous fat. In this report, an infant affected with Niemann-Pick disease and recurrent lobular panniculitis is described and discussed.

Panniculitis. Part II. Mostly lobular panniculitis

The second part of our review of panniculitis summarizes the clinicopathologic features of the mostly lobular panniculitides. Erythema induratum of Bazin (nodular vasculitis) represents the most common variant of lobular panniculitis with vasculitis, although controversy persists about the nature of the involved vessels. Mostly lobular panniculitides without vasculitis comprise a series of disparate disorders. These include sclerosing panniculitis that results from chronic venous insufficiency of the lower extremities; panniculitis with calcification of the vessel walls such as calciphylaxis and oxalosis; and inflammatory diseases with crystals within the adipocytes such as sclerema neonatorum, subcutaneous fat necrosis of the newborn, and poststeroid panniculitis. Connective tissue diseases, such as systemic lupus erythematosus and dermatomyositis, pancreatic diseases, and alpha(1)-antitrypsin deficiency may also show a mostly lobular panniculitis with characteristic histopathologic features. Lobular panniculitis may also be an expression of infections, trauma, or factitial causes involving the subcutaneous fat. Lipoatrophy refers to a loss of subcutaneous fat due to a previous inflammatory process involving the subcutis, and it may be the late-stage lesion of several types of panniculitis. In contrast, lipodystrophy means an absence of subcutaneous fat with no evidence of inflammation and often the process is associated with endocrinologic, metabolic, or autoimmune diseases. Finally, cytophagic histiocytic panniculitis is the term that has been used to describe two different processes: one is inflammatory, a lobular panniculitis, and the other one is neoplastic, a subcutaneous T-cell lymphoma. The only common feature of these two different processes is the presence of cytophagocytosis in the lesions. (J Am Acad Dermatol 2001;45:325-61.)

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the pathogenesis, clinical manifestations, histopathologic findings, and treatment options for the most frequent variants of the lobular panniculitides.

Panniculitis in juvenile dermatomyositis

Panniculitis is a rarely reported clinical finding in dermatomyositis. We present a 14-year-old African American boy with a 4-year history of dermatomyositis referred for evaluation of tender, indurated plaques and nodules on the trunk and proximal extremities. A biopsy specimen revealed epidermal and dermal changes consistent with dermatomyositis. Although calcification was absent, a striking lobular panniculitis was observed. A total of seven cases of clinical panniculitis in association with dermatomyositis have been published. As in our patient, it typically presents as indurated, tender plaques and nodules on the arms, thighs, and buttocks. Although in the vast majority of cases panniculitis found in association with dermatomyositis is subclinical and represents an incidental histopathologic finding, the case we present further emphasizes the need to recognize panniculitis as a rare, but clinically relevant pathologic feature seen in certain lesions of juvenile dermatomyositis.

Erythema nodosum in children: a study of 27 patients

Erythema nodosum (EN) seems to occur in children more rarely than in adults. It still remains the most frequent acute panniculitis, for which the diagnosis is almost always clinical. In a retrospective study of 27 pediatric patients, we have attempted to clarify the clinical spectrum and prognosis of this disease and discuss the differential diagnosis of nodular eruptions on the lower limbs of children. In almost half the patients of our series, the cause of EN remained undetermined. Streptococcal infections (usually of the pharynx) were the most common cause of EN in children (22% of patients in our series), followed by Yersinia infection in about 15% of patients. Tuberculosis, an important cause in the past, was never found, but must always be excluded. A benign course was noted in all patients. Erythema nodosum is easily recognized clinically, but other subcutaneous lesions, especially nodular vasculitis and Schönlein-Henoch purpura, have to be excluded by pathologic study, in cases of atypical presentation or long duration.

Subcutaneous T-cell lymphoma presenting as panniculitis in children: report of two cases

Two cases of peripheral T-cell lymphoma with primarily subcutaneous involvement and clinically presenting as panniculitis were reported in two children. One child developed florid hemophagocytic syndrome and was treated by combination chemotherapy but died 14 months later of disseminated fungal infection. The other child had mild systemic symptoms but no histological evidence of hemophagocytosis. Despite a more florid lymphomatous infiltrate, he attained a complete remission after a short course of prednisone and remains symptom-free at 3 years. Our report confirms that subcutaneous T-cell lymphoma is a distinct clinicopathological entity and highlights the two modes of clinical presentation. The development of florid hemophagocytic syndrome indicates a bad prognosis. This entity must be distinguished from other causes of panniculitis and immunophenotypic analysis of the atypical cells is essential in the diagnosis. Combination chemotherapy is the treatment of choice, but in patients who pursue an indolent course the administration of aggressive chemotherapy may be deferred.

Panniculitis and fever in children

We describe three children with panniculitis and associated systemic manifestations including fever. Histopathologic features, such as the presence of lobular or septal inflammation, presence of vasculitis, character of the cellular infiltrate, and presence of erythrophagocytosis, were useful in classifying this group of panniculitides. In one patient with subcutaneous polyarteritis nodosa, corticosteroid therapy was effective; in two other patients with histiocytic cytophagic panniculitis, there were poor responses to steroids, intravenously administered immune globulin, dapsone, or antimalarial drugs; cyclosporine was very effective and appeared to be the drug of choice.

Juvenile dermatomyositis associated with partial lipoatrophy

A 26-year-old woman developed partial lipoatrophy 12 years after juvenile dermatomyositis was diagnosed. Renal function was normal, but she had other features typically associated with partial lipoatrophy, including hepatomegaly, acanthosis nigricans, hypertrichosis, and hyperinsulinemia.

Panniculitis: a report of four cases and literature review

Panniculitis is a disease with many causes and associations. The classification of clinical subtypes is unsatisfactory and hampered by the use of eponyms. Four children with recurring panniculitis are described and their histology presented. Three had subcutaneous fat atrophy with lobular panniculitis on biopsy; all responded well to corticosteroids. The fourth child had a septal panniculitis with no atrophy of subcutaneous tissues and only a partial response to treatment with corticosteroids. A widely accepted precise histological classification of panniculitis is needed to enable accurate predictions of the outcome of this serious disorder.

Dermatomyositis associated with multifocal lipoatrophy

A 10-year-old boy had juvenile dermatomyositis and multiple asymmetric lesions of lipoatrophy. The lipoatrophy had occurred without preceding clinical evidence of inflammation. Biopsy specimens of the skin confirmed a lobular panniculitis. This is the first report of the association of lipoatrophy and juvenile dermatomyositis.