Metabolic panniculitis: alpha-1 antitrypsin deficiency panniculitis and pancreatic panniculitis

Skin manifestations of pancreatic diseases

Although symptoms of pancreatic diseases such as pancreatitis, acute and chronic and, carcinoma of the pancreas are mainly gastrointestinal in nature, the extra-pancreatic symptoms are also important. These include skin symptoms, such as pancreatic panniculitis, acanthosis nigricans, livedo reticularis, necrolytic migratory erythema, cutaneous signs of hemorrhage, as in persons with severe acute pancreatitis, or the finding of cutaneous metastases of pancreatic carcinoma, which may be a sign of advanced disease. The pancreas is therefore one of those organs for which diagnosis and therapy are often multidisciplinary. In this review article, we summarize current knowledge of the possible skin manifestations of pancreatic disorders.

A Tale of Two Ps: Panniculitis Secondary to Acute Pancreatitis

Pancreatic panniculitis (PP) is a rare variant of panniculitis that affects patients with pancreatic disorders, most commonly pancreatic malignancy or acute/chronic pancreatitis. Patients often present with painful, erythematous nodules on their lower extremities that may undergo spontaneous ulceration and necrosis. Treatment is largely supportive and should address the underlying pancreatic disease.

Cutaneous Manifestations in Pancreatic Diseases-A Review

Pancreatic pathology, comprising acute and chronic pancreatitis, autoimmune pancreatitis and pancreatic neoplasms, primarily presents with gastrointestinal symptoms and signs; however, it is well recognized that it can also associate a wide range of extra-digestive features. Among these systemic manifestations, cutaneous involvement plays an important role both as a diagnostic clue for the pancreatic disease itself and serving as a prognostic factor for the severity of the condition. Recognition of these cutaneous signs is, however, far from being satisfactory, all the more as some of them are relatively rare. In the current review, we discuss skin involvement in pancreatic diseases, referring to pancreatic panniculitis, cutaneous hemorrhagic manifestations, skin metastasis, acanthosis nigricans, livedo reticularis, necrolytic migratory erythema and cutaneous fistula. We highlight the clinical characteristics, treatment and prognostic value of these lesions. Better awareness among medical specialties other than dermatology is needed for detection of the skin clues associated with pancreatic pathology.

Pyoderma gangrenosum-like necrotizing panniculitis associated with Imatinib: A case report

Imatinib mesylate is a small tyrosine kinase inhibitor that targets BCR-ABL, ckit and platelet-derived growth factor receptor. It is prescribed by hematologists for chronic myeloid leukemia and acute lymphoblastic leukemia and by oncologists for Gastrointestinal Stromal Tumors (GIST). Cutaneous reactions to Imatinib are common but their incidence and severity widely varies between patients. A self-limited skin rash is the most common adverse effect but there have been reported cases of patients with maculopapular rash, pigmentary changes, superficial edema and rarer and clinically distinctive features such as lichenoid reactions or psoriasis. We here describe for the first time a case of pyoderma gangrenosum-like necrotizing panniculitis, a rare dermatological condition, after initiating therapy with Imatinib.

Managing panniculitis in alpha-1 antitrypsin deficiency: Systematic review of evidence behind treatment

AIM

To systematically review literature for management of alpha-1 antitrypsin deficiency (AATD) panniculitis.

METHODS

Multiple databases were searched using combinations of pertinent terms. Articles were selected describing panniculitis treatment in patients with AAT < 11 μmol and/or PiZZ genotype, with no language limitation. All relevant articles were accessed in full text. Independent review of abstracts and full manuscripts was conducted by 2 reviewers, and quality assessment by one reviewer (checked by a second). Data extraction was conducted by one reviewer (checked by a second). Narrative synthesis only was conducted, as data were unsuitable for meta-analysis.

RESULTS

Thirty-two case reports and 4 case series were found. Augmentation therapy (infusions of plasma-derived AAT) was the most successful, with complete resolution of symptoms in all patients. Dapsone is a less expensive option, and it achieved clinical resolution in 62% of patients, but it is very poorly tolerated. Among other single-agent antibiotics, doxycycline was the most successful with complete clinical resolution seen in 33% of patients. Immunosuppressants were largely unsuccessful; 80% of patients exhibited no response. Liver transplantation and therapeutic plasma exchange displayed complete resolution in 66% of patients. Other strategies, such as non-steroidal anti-inflammatory drugs or antibiotics other than dapsone did not show sufficient response rates to recommend their use. Authors note the risk of bias imposed by the type of evidence (case reports, case series) available in this field.

CONCLUSION

Dapsone is the recommended first line therapy for AATD panniculitis, followed by augmentation therapy. Plasma exchange may be an alternative in the setting of rapidly progressive disease.

[Pancreatic Panniculitis in Patients with Chronic Pancreatitis: Case Report and Review of Literature]

Pancreatic panniculitis is a rare complication characterized by subcutaneous fat necrosis associated with pancreatic disease. It has been postulated that pancreatic panniculitis is caused by the systemic activity of pancreatic enzymes that lead to microcirculatory disturbances. We report a 41-year-old heavy alcoholic woman with pancreatic panniculitis that coexisted with acute and chronic pancreatitis. She was diagnosed with chronic pancreatitis and alcoholic liver cirrhosis 5 years ago. She presented with multiple, tender, erythematous, subcutaneous nodules with heat sensation on both lower legs. Laboratory evaluation revealed an increase in the serum blood amylase and lipase. Histopathologic findings showed fat necrosis with inflammation around the necrotic subcutaneous fat tissue. The lesions subsided gradually with an improvement of acute pancreatitis.

Pancreatic panniculitis associated with pancreatic carcinoma: A case report

INTRODUCTION

Pancreatic panniculitis is a very rare complication of pancreatic cancer, most often accompanying rare acinar cell carcinoma. We herein report a case of pancreatic panniculitis that was associated with pancreatic mucinous adenocarcinoma.

PATIENT INFORMATION

A 57-year-old male was referred to our hospital for weight loss. A physical examination revealed subcutaneous nodules on his lower extremities. The blood test showed abnormal increases in amylase, lipase, and carbohydrate antigen 19-9 levels. A computed tomography scan detected a hypodense 2 × 1.5 cm solid mass with an unclear margin in the head of the pancreas. The biopsy of subcutaneous nodules on the lower extremities was conducted and revealed lobular panniculitis. Pancreatic cancer and pancreatic panniculitis were strongly suspected. After the administration of octreotide acetate and the Whipple procedure, the serous amylase and lipase levels returned to normal, and the pancreatic panniculitis had almost resolved by 4 weeks later.

CONCLUSION

Pancreatic panniculitis is a rare complication of pancreatic cancer. However, in the presence of a pancreatic mass, as in this case, clinicians should be aware that panniculitis may be the sentinel of pancreatic carcinoma.

Detection of Cancer-Specific Proteases Using Magnetic Relaxation of Peptide-Conjugated Nanoparticles in Biological Environment

Protease expression is closely linked to malignant phenotypes of different solid tumors; as such, their detection is promising for diagnosis and treatment of cancers, Alzheimer's, and vascular diseases. Here, we describe a new method for detecting proteases by sensitively monitoring the magnetic relaxation of monodisperse iron oxide nanoparticles (IONPs) using magnetic particle spectrometer (MPS). In this assay, tailored peptides functioning as activatable nanosensors link magnetic nanoparticles and possess selective sites that are recognizeable and cleaveable by specific proteases. When these linker peptides, labeled with biotin at N- and C-terminals, are added to the neutravidin functionalized IONPs, nanoparticles aggregate, resulting in well-defined changes in the MPS signal. However, as designed, in the presence of proteases these peptides are cleaved at predetermined sites, redispersing IONPs, and returning the MPS signal(s) close to its preaggregation state. These changes observed in all aspects of the MPS signal (peak intensity, its position as a function of field amplitude, and full width at half-maximum-when combined, these three also eliminate false positives), help to detect specific proteases, relying only on the magnetic relaxation characteristics of the functionalized nanoparticles. We demonstrate the general utility of this assay by detecting one each from the two general classes of proteases: trypsin (digestive serine protease, involved in various cancers, promoting proliferation, invasion, and metastasis) and matrix metalloproteinase (MMP-2, observed through metastasis and tumor angiogenesis). This MPS based protease-assay is rapid, reproducible, and highly sensitive and can form the basis of a feasible, high-throughput method for detection of various other proteases.

Pancreatic panniculitis - a cutaneous manifestation of acute pancreatitis

BACKGROUND

Pancreatic panniculitis is a rare complication of pancreatic disease occurring in 2% to 3% of all patients, most commonly those with acute or chronic pancreatitis.

MAIN OBSERVATIONS

We report the case of a pancreatic panniculitis associated with acute pancreatitis in a 63-year-old man. He presented with a 2-day history of multiple tender subcutaneous nodules, followed by nausea, vomiting, severe epigastric pain and loss of appetite, hours before admission. Laboratory and radiologic findings revealed acute pancreatitis. Histopathological examination from a skin biopsy specimen taken from a nodule showed a mostly lobular panniculitis with "ghost cells", without vasculitis. Nodules disappeared with the resolution of acute pancreatic inflammation, as amylase and lipase levels returned to normal.

CONCLUSIONS

Panniculitis may be the first manifestation of pancreatic disease. Therefore clinicians must have a high index of suspicion for the diagnosis of pancreatic panniculitis.

Catastrophic wounds

BACKGROUND

This article summarizes information presented at the Wound Healing Subspecialty Symposium of the Annual Conference of the Canadian Dermatology Association held in Ottawa in June 2012.

OBJECTIVE

To provide continuing medical education on wound healing for dermatologists.

METHODS

A review of the pertinent literature was performed by the author in order to prepare the lecture and subsequent article.

RESULTS

The review found that necrotizing faciitis, hypertensive ulceration, antiphospholipid syndrome and α1-antitrypsin syndrome are entities that contribute to catastrophic wounds seen in wound healing clinics and in private offices.

CONCLUSION

It is most important to have a high index of suspicion for these four conditions because early diagnosis can be life-saving with necrotizing faciitis, pain-relieving in ulcers caused by hypertension, and antiphospholipid syndrome, and can result in early treatment in α1-antitrypsin deficiency.

The discovery of α1-antitrypsin and its role in health and disease

α1-Antitrypsin (AAT) is the archetype member of the serine protease inhibitor (SERPIN) supergene family. The AAT deficiency is most often associated with the Z mutation, which results in abnormal Z AAT folding in the endoplasmic reticulum of hepatocytes during biogenesis. This causes intra-cellular retention of the AAT protein rather than efficient secretion with consequent deficiency of circulating AAT. The reduced serum levels of AAT contribute to the development of chronic obstructive pulmonary disease (COPD) and the accumulation of abnormally folded AAT protein increases risk for liver diseases. In this review we show that with the discovery of AAT deficiency in the early 60s as a genetically determined predisposition to the development of early-onset emphysema, intensive investigations of enzymatic mechanisms that produce lung destruction in COPD were pursued. To date, the role of AAT in other than lung and liver diseases has not been extensively examined. Current findings provide new evidence that, in addition to protease inhibition, AAT expresses anti-inflammatory, immunomodulatory and antimicrobial properties, and highlight the importance of this protein in health and diseases. In this review co-occurrence of several diseases with AAT deficiency is discussed.