An unreported case of pancreatic panniculitis in a liver transplant patient

Pancreatic panniculitis is an uncommon condition that can occur in association with pancreatic disease. Most of the cases reported to date were associated with acute or chronic pancreatitis and pancreas cancer. Recently, development has been described in kidney transplant patients and secondarily to allograft pancreatitis in a pancreas-kidney transplant recipient. Both findings suggest that immunological processes may be involved in the pathogenesis of this entity. We report for the first time a case of acute pancreatitis associated with pancreatic panniculitis in a patient who underwent a liver transplant 10 months before. A 69-year-old man with a history of epigastric pain of a few days of evolution was presented with painful subcutaneous nodules on both legs. Blood chemistry showed raised serum amylase and lipase levels. Ultrasonography and multislice CT scan were suggestive of an acute pancreatitis. A skin biopsy showed typical features of pancreatic panniculitis which included lobular panniculitis with lipocyte degeneration with ghost cells. The administration of octreotide resulted in both a rapid improvement of symptoms and a disappearance of skin lesions. Liver transplant specialists should be aware that the pancreatic panniculitis could be a manifestation ofpancreas disease in patients who have undergone l ver transplantation.

[Weber-Christian disease: unknown etiology systemic panniculitis]

Panniculitis is an inflammation occurring within adipose tissue. This process is often associated with auto-immune diseases, infections, malignancy and others diseases of unknown cause. We report a 16-year-old woman with constitutional symptoms and relapsing nonsuppurative nodular panniculitis. The etiological study didn't identify any associated disease, on admission or in 2,5 years of follow-up. This is a case of Weber-Christian disease with a favourable corticosteroid therapy result. The authors present a Weber-Christian disease bibliographic revision.

Pancreatic panniculitis associated with allograft pancreatitis and rejection in a simultaneous pancreas-kidney transplant recipient

Pancreatic panniculitis is an uncommon condition that can occur in association with pancreatic disease. We present a case of pancreatic panniculitis in a female pancreas-kidney transplant recipient 5 months post-transplant. The patient was on standard immunosuppressive medications and had acute rejection of her renal allograft. The diagnosis of allograft pancreatitis and rejection presenting with pancreatic panniculitis was supported clinically, histopathologically and by laboratory and imaging data. This is the fourth case of pancreatic panniculitis occurring in a transplant recipient and the first in a simultaneous pancreas-kidney transplant recipient. It is also the first case associated with allograft rejection. Clinicians should be aware that pancreatic panniculitis may be a manifestation of underlying allograft pancreatic disease.

[Painful, partly discolored livid nodules and bruises of all extremities in a 68-year-old Vietnamese man]]

Ein Erythema nodosum kann Ausdruck einer Vielzahl von Erkrankungen sein. Da oft ernste Erkrankungen ursächlich zugrunde liegen (maligne Lymphome, Tuberkulose; Sarkoidose) stellt das idiopathische Erythema nodosum eine Ausschlussdiagnose dar. Eine sorgfältige Diagnostik ist entscheidend und bestimmt schliesslich das therapeutische Vorgehen.

[Nodular panniculitis--a paraneoplastic syndrome in pancreatic carcinoma]

A 68-year-old woman is described, who suffered from painful, subcutaneous nodules on her lower extremities. The clinical investigations revealed a solitary liver metastasis of a pancreatic carcinoma removed seven years before. Her serum lipase was 6088 U/l (normal value < 190 U/l). After embolisation and surgical resection of the metastasis the serum lipase level became unmeasurably low and the painful nodular panniculitis disappeared completely. Nodular panniculitis is a paraneoplastic syndrome not well known among physicians, which was easily treatable in our case.

Pfeifer-Weber-Christian's panniculitis in an obese patient with antinuclear antibody-positive leukocytoclastic vasculitis

Pfeifer-Weber-Christian's panniculitis is a rare syndrome characterized by fever, arthralgias, fatigue and recurrent nodular panniculitis. It has been associated with pancreatic diseases, trauma, connective tissue diseases, alpha-1-antitrypsin deficiency, systemic lupus erythematosus, infections, lymphoproliferative diseases and neoplasias. We report the case of a 43-year-old obese male patient who presented with asthenia, arthralgias, intermittent fever, skin erythema and a large hard-elastic tumor of the right calf. Laboratory analysis revealed increased values of the immunophlogosis parameters and positivity for serum antinuclear antibodies. Surgical drainage of the abscess-like tumor mass, revealed leakage of a sterile, subflavious, oily and thick liquid; a skin biopsy showed intra and perivascular infiltration by neutrophils, diagnostic for leukocytoclastic vasculitis. Treatment with prednisone induced clinical improvement and normalization of the laboratory data. The clinical picture, laboratory data and efficacy of prednisone therapy confirmed that the patient developed Pfeifer-Weber-Christian's panniculitis in the clinical setting of an antinuclear antibody-positive leukocytoclastic vasculitis.

Clinicopathologic evaluation of nodular cutaneous lesions of Behçet syndrome

Among the cutaneous manifestations, nodular lesions are rather common in Behçet syndrome. The histologic nature of these lesions has been a matter of controversy. To establish their distinguishing features, biopsy specimens from nodular lesions of 24 patients with Behçet syndrome, 25 with nodular vasculitis (NV), and 20 with erythema nodosum (EN) were compared. Statistical analysis revealed insignificant differences between most of the histologic features of Behçed syndrome and NV. However, neutrophil-predominating infiltrate in the subcutis was more common in Behçet syndrome, while necrosis and granuloma formation were encountered more frequently in NV. The differences between Behçed syndrome and EN were more significant. Septal panniculitis, lymphocyte-predominating infiltrate, absence of many vascular changes as well as vasculitis, and necrosis were features in favor of EN. Nodular lesions of Behçet syndrome are mainly neutrophilic vascular reactions with histologic features similar to NV but significantly differing from EN associated with other systemic diseases.

A case of cytophagic histiocytic panniculitis associated with exertional rhabdomyolysis

An 18-year-old man who suffered from panniculitis involving the entire left lower limb after exertional rhabdomyolysis is reported. A high fever (>39 degrees C) and leukocytosis (>20,000/microL) persisted for 1 week, and his general status deteriorated rapidly into pre-disseminated intravascular coagulation, complicated by pleural effusion and prolonged clotting time. His condition was dramatically improved by steroid pulse therapy and he has remained in good health for the 20 months since discharge. Histologic examination of subcutaneous tissue from the swollen left lower limb revealed pleomorphic small, medium or large lymphocytes, macrophages and neutrophils infiltrating the edematous subcutaneous adipose tissue in a lobular panniculitis-like pattern. The majority of inflammatory cells were T lymphocytes, with equal proportions of CD4+ and CD8+ cells. As polymerase chain reaction did not show bands suggesting T cell receptor gamma gene rearrangement, the proliferation of T lymphocytes was considered to be polyclonal. The T lymphocytes also expressed Fas ligand, suggesting the involvement of Fas-mediated cytotoxicity. This case may represent a new category of cytophagic histiocytic panniculitis induced by exertional rhabdomyolysis.

Successful treatment of a patient with febrile, lobular panniculitis (Weber-Christian disease) with oral cyclosporin A: implications for pathogenesis and therapy

We report a 15-year-old Japanese girl with severe systemic Weber-Christian disease (WCD) who presented with acute onset of high fever associated with tender subcutaneous nodules. Laboratory tests showed an elevated serum concentration of lactate dehydrogenase (LDH), leukopenia, and coagulation abnormalities. The anti-nuclear and anti-DNA antibodies were negative, and the serum pancreatic enzymes and alpha 1-antitrypsin levels were normal. Pulse steroid therapy was not effective, and eventually cerebellar hemorrhage occurred. After initiation of oral cyclosporin A (CyA) therapy, fever came down and her clinical condition improved markedly. Extremely high serum concentrations of interferon-gamma (IFN-gamma) and soluble interleukin-2 receptor (sIL-2R) in this patient returned to normal with CyA therapy. These findings suggest that T-cell immune responses are involved in the pathogenesis of WCD, and that CyA is effective against the disease via suppression of T-cell reactions.

[Hepatic artery ligation for liver metastasis of a acinar cell carcinoma of the pancreas revealed by a nodular panniculitis]

We report the case of a 67-year-old-man presenting with pancreatic acinar cell carcinoma revealed by dermatological manifestations of cytosteatonecrosis and treated by hepatic artery ligation. The pancreatic etiology of these lesions was suspected due to hyperlipasemia, and was confirmed by abdominal computerized tomography showing a pancreatic tumor and multiple liver nodules, and by histological examination of one of these lesions. Because of symptomatic treatment failure, rapid impairment of patient's general condition, and by analogy with the treatment of hepatic metastases of neuroendocrine tumors, hepatic artery ligation was performed. Lipasemia decreased markedly and symptoms disappeared for 45 days. Hepatic artery obstruction may be used for emergency treatment of secreting liver metastases.

[Endoscopic treatment of subcutaneous fat necrosis secondary to pancreatic-vascular fistula: apropos of a case]

PATIENT AND METHOD

We report the case of a 68-year-old man who presented a pancreatic tumor with a pancreato-vascular fistula and a Weber-Christian syndrome. Pancreatic enzymes levels at the admission were high: amylasemia 2,470 IU/L (N < 110) and lipasemia 11,700 IU/L (N < 220). The treatment consisted in total parenteral nutrition and somatostatin (100 micrograms x 3/day). Because we noted neither clinical nor biological improvement after 10 days of treatment, we performed an endoscopic retrograde pancreatography. During this examination, we put a 7 French diameter prosthesis through the Wirsung stenosis.

RESULTS

No problem arose after endoscopy: since the day after the endoscopy, pancreatic enzymes decreased by half and become normal in 4 days; arthralgias and cutaneous injuries, both caused by cytosteatonecrosis, disappeared respectively in 5 and 10 days. There is no evidence of subsequent recurrence after 3 months of follow-up.

CONCLUSION

Pancreatic endoscopic prosthesis can replace the surgical treatment of pancreato-vascular fistula with a good efficacy.

Panniculitis: recent developments and observations

Dermatopathologists rarely greet a biopsy of panniculitis with total confidence that a specific, definitive diagnosis will be rendered. As with many other areas in dermatopathology, our understanding of the pathogenesis of many forms of panniculitis is incomplete. This article examines a subset of panniculitis primarily from a pathogenetic standpoint, with the intention of providing a differential diagnosis for those cases in which ischemic changes are seen in the subcutis. The diverse group of conditions evoked by this approach also shares the distinction of having been the focus of nosologic and causative controversy, both historically and currently. In particular, stasis-associated sclerosing panniculitis, vascular calcification-cutaneous necrosis syndrome (calciphylaxis), oxalosis, and nodular vasculitis-erythema induratum are examined in depth. Erythema nodosum and variants, other granulomatous panniculitides, and panniculitides showing cytophagocytosis are also discussed with current perspectives.

[Scrotal panniculitis due to cold: a pseudo-tumoral lesion in the prepubertal child. Report of a case]

We reported a case of scrotal panniculitis in a 7 year-old boy after exposure to cold by swimming in cold sea water. Scrotal cold panniculitis is an unusual, confined to prepuberal patients. This entity must be known to avoid surgical exploration because injuries subside spontaneously within few weeks.

Nodular intra-abdominal panniculitis: an accompaniment of colorectal carcinoma and diverticular disease

Intra-abdominal panniculitis is a tumour-like inflammatory condition of adipose tissue. The aetiology and pathogenesis of the disease is unknown, but a number of associated diseases have been recorded. It has been customary to deal with only primary cases in the literature. This study was undertaken in order to describe the entire spectrum of the disease including primary as well as secondary cases. Eleven patients are reported, nine of which had an associated colorectal disease in direct continuity with areas of intra-abdominal panniculitis. It is concluded that intra-abdominal panniculitis should not be regarded as a specific nosological entity but merely a result of injury to the fat cells. Intra-abdominal panniculitis is seen more often as a secondary local phenomenon than as a primary condition, and in both cases it is associated with considerable differential diagnostic problems. Primary diseases involved are, among others, colorectal carcinoma and diverticulosis. The aetiologic agent(s) are still unknown, but substances liberated from a damaged bowel might play a pathogenetic role.

[Pancreatogenic panniculitis]

A 40-year-old woman who had been treated for mesangiocapillary glomerulonephritis by renal transplantation, and who still used furosemide, azathioprine, cyclosporine and prednisone, was admitted with multiple erythematous nodes on the lower legs. Pancreatogenic panniculitis caused by pancreatitis was diagnosed. The patient died with a haemorrhagic and necrotic pancreas one month after admission. Pancreatogenic panniculitis occurs in 2-3% of patients with pancreatitis or pancreatic carcinoma. It can be a first manifestation of an undetected pancreatic disease.

[Acute disseminated multinodular non-recurrent adiponecrosis. Cutaneous manifestations of recent toxoplasmosis]

Acute disseminated multinodular non suppurative panniculitis in a 3 year-old boy is reported. The diagnosis was histologically confirmed. Detection of high levels of specific serum IgM favored a diagnosis of acute toxoplasmosis. The relationship between panniculitis and acute toxoplasmosis is discussed.

Cold panniculitis in children (Haxthausen's disease)

This report describes the rarely recognized, but probably quite common, cold panniculitis, which occurs predominantly in infants, as red indurated plaques or nodules on the face, following exposure to severe cold.

Gout presenting as lobular panniculitis

A 37-year-old man presented with panniculitis of the legs that, on biopsy, showed aggregates of crystals whose appearance suggested sodium urate. Based on this finding, a uric acid level was obtained which proved to be markedly elevated. The patient subsequently developed gouty arthritis. Gout should be added to the differential diagnosis of causes of panniculitis, and biopsy specimens of panniculitis should be carefully examined for crystals.

[Pancreatic cytosteatonecrosis]

If cutaneous panniculitis, made of dermo-hypodermic nodules, is the most constant manifestation of pancreatic cytosteatonecrosis, articular and bony localizations are quite frequent and sometimes the first manifestation of the disease. Articular lesions: monoarthritis, oligo-arthritis and mostly polyarthritis, often assume a very inflammatory picture; the synovial fluid is oily or puriform, and has a high content of polynuclear cells or macrophages with a foamy cytoplasm, lipid droplets, triglycerides, non-esterified fatty acids, and pancreatic enzymes; the most typical synovial lesion is a cytosteatonecrosis with adipocytes showing a huge lipidic vacuole. The bony lesions are mostly osteolytic, microgeodic lesions, or more extended ones, pseudo-tumoral without soft tissue invasion: more rarely, there is a periosteal thickening, bony infarctions, or epiphyseal osteonecrosis; these lesions do not always demonstrate a hyperfixation on scintigrams. The physiopathology of these various lesions is usually linked to a diffusion of pancreatic lipases, but other enzymes or enzymatic inhibitors also intervene, as well as a cytotoxic and local inflammatory activity of the fatty acids themselves. Surgical treatment of the pancreatic lesions, when possible, is the only treatment that is truly effective.

Subcutaneous Whipple's disease

Cutaneous findings in Whipple's disease are rare and often exhibit nonspecific lesions such as hyperpigmentation, subcutaneous nodules, and erythema nodosum. A 37-year-old black man with previously documented Whipple's disease developed soft, subcutaneous nodules on the chin, neck and extremities. Biopsy of these nodules showed a nonspecific panniculitis and intracellular inclusions stained by periodic acid-Schiff reagent. The inclusions were of the type thought characteristic of Whipple's disease. These findings indicate that patients with Whipple's disease can have characteristic skin findings that can be documented by skin biopsy.

Subcutaneous nodules in Pseudomonas sepsis

Approximately 60 nontender, nonfluctuant, red, hot subcutaneous nodules developed on the trunk, extremities, and face due to Pseudomonas aeruginosa septicemia in a 56-year-old woman with stage III ovarian adenocarcinoma. Two years later, these lesions appeared atrophic with central scarring. Complete eradication with systemic antibiotics and without incision and drainage was accomplished.

Eosinophilic panniculitis: a clinicopathologic study

Study of 18 patients with biopsy diagnoses of eosinophilic panniculitis revealed diverse patterns of systemic disease, including Wells' syndrome, vasculitis, atopy, and erythema nodosum as well as localized panniculitis. Significant associated diseases included psychiatric illness, 6 (drug dependency, 4); atopy, 5 (asthma, 3); malignancies, 5; immune complex vasculitis, 4; thyroid disease, 2; Wells' eosinophilic cellulitis, 2; glomerulonephritis and sarcoidosis, 1 each. The skin lesions varied from urticarial papules and plaques to purpura, pustules, and ulcerative lesions but always included a nodular subcutaneous component, frequently as a presenting complaint. Eosinophilic panniculitis is a non-specific finding that can signify localized disease, such as an insect bite or injection lipophagic granuloma in a drug-dependent patient, or systemic lymphoma or immune reactive disease. Eosinophilic panniculitis in erythema nodosum is perhaps its most confusing presentation.

Panniculitis associated with a pancreas divisum

A case is presented of a 67-year-old man with chronic abdominal pain thought to be due to peptic ulcer disease. He developed nodules of panniculitis (nodular fat necrosis), resulting in extensive investigations for pancreatic disease. He was ultimately found to have low-grade pancreatitis associated with a pancreas divisum. Surgical treatment of this congenital anomaly resulted in complete resolution of the panniculitis and abdominal pain. Panniculitis as a manifestation of pancreatitis is well documented. However, panniculitis leading to the discovery of chronic pancreatitis with a surgically treatable ductal abnormality has not been previously reported. In cases of unexplained nodular fat necrosis, an aggressive search for a pathologic condition of the pancreas is indicated.

Polymyositis presenting with panniculitis

Although microscopic areas of panniculitis may frequently occur in patients with dermatomyositis and polymyositis, large, clinically obvious plaques are unusual. We report a patient with polymyositis who initially had panniculitis of the thigh. Histologically, a lobular lymphoplasmacytic infiltrate was present in the subcutis.

Fatal panniculitis

The Weber-Christian syndrome (relapsing nodular panniculitis) displays a clinical spectrum varying from short, self-limited, or intermittent disease episodes to persistent disease with fatal outcome. Inflamed adipose tissue is exclusively subcutaneous in some patients and is both subcutaneous and perivisceral in others. Inflammation of fat may induce a focal cutaneous or a systemic extracutaneous histiocytic proliferative response in which hemophagocytosis may be a frequent characteristic. Major causes of death--sepsis, hepatic failure, hemorrhage, and thrombosis--are identical in the patients with and without the systemic histiocytic proliferation. Inflammation in fat, of and by itself, may be associated with significant morbidity and mortality, regardless of specific histopathology or inciting factors.

Eosinophilic panniculitis

A patient is described who developed sore throat, palpable purpura, and a distinctive panniculitis. The pathologic alterations in the subcutis were similar to what Wells described in the dermis as eosinophilic cellulitis. In our experience the presence of such a picture primarily in the subcutis is unique. Streptococcus is implicated as a possible antigenic stimulus for the process in this patient.

Cyclophosphamide-induced remission in Weber-Christian panniculitis

A patient with Weber-Christian panniculitis is described in this report in which treatment with prednisone and hydroxychloroquine caused no improvement of the disease, and even led to a worsening of the symptoms. In contrast, administration of oral cyclophosphamide led to a rapid remission of the disease. As Weber-Christian disease has no known aetiology and no specific treatment has been established, the successful therapy with the cytostatic drug cyclophosphamide may shed light on the pathogenesis of Weber-Christian panniculitis.

Panniculitis in connective tissue disease

Specific and nonspecific panniculitis occur in connective tissue diseases. Microscopic studies of the epidermis and dermis, immunofluorescent microscopy, and extensive serologic testing may aid in the diagnosis and classification of these unusual syndromes. Connective tissue panniculitis and focal lipoatrophy may be forms of immunoreactive panniculitis or connective tissue disease (or both) in which typical microscopic, serologic, or other events related to classic connective tissue disease have not occurred.