Ultrasound analysis for pancreatic panniculitis: A case report / 中南大学学报(医学版)

Pancreatic panniculitis (PP) is a necrotizing inflammation of subcutaneous fat that is a rare complication of pancreatic disease appearing in 2% to 3% of all patients. It is more common in the elderly and often affects the extremities. It presents as skin inflammation with pain and erythema nodules. We report a case of acute pancreatitis associated with PP in an old female. She was admitted for vomiting and abdominal pain for 3 days and presented with a 2-week history of erythematous subcutaneous nodules on her legs. Laboratory and ultrasonic findings revealed acute pancreatitis. High frequency ultrasound showed hypoechoic foci in subcutaneous soft tissue layer and adipose layer. Histopathological examination confirmed the diagnosis of PP. Nodules disappeared with the resolution of acute pancreatic inflammation. PP may be the first manifestation of pancreatic disease. Imaging features of this pathology are seldom described and ultrasonic diagnosis experience is worth to be accumulated.

Comportamiento clínico-epidemiológico del eritema nudoso en el Hospital Provincial Docente Clínico Quirúrgico León Cuervo Rubio / Epidemiological clinical behavior of erythema nodosum at the Provincial Teaching Clinical Surgical Hospital Leon Cuervo Rubio

RESUMEN Introducción: el eritema nudoso es la variante clínico-patológica más frecuente de la paniculitis. Es una reacción cutánea inmunológica en respuesta a un amplio espectro de agentes etiológicos. Objetivo: caracterizar el comportamiento clínico-epidemiológico del eritema nudoso. Materiales y métodos: se realizó un estudio descriptivo, prospectivo y longitudinal en pacientes con diagnóstico de eritema nudoso, ingresados en el Hospital Provincial Docente Clínico Quirúrgico León Cuervo Rubio, de Pinar del Río, en el período de enero de 2017 a diciembre de 2018. El universo estuvo constituido por 34 pacientes con diagnóstico clínico de eritema nudoso, hospitalizados en los servicios de Medicina Interna y Dermatología. Para la recogida de la información se utilizaron la historia clínica, el examen físico y los exámenes de laboratorio. Se utilizaron métodos teóricos, empíricos y estadísticos; de los últimos se empleó la estadística descriptiva a través de frecuencias absolutas y porcentaje. Resultados: el mayor grupo de pacientes estuvo entre 30 y 39 años, y fue del sexo femenino. Las lesiones fueron más frecuentes en los meses de invierno. El tipo de eritema nudoso idiopático prevaleció. Predominó el tiempo de evolución de 1 a 3 meses. Como causa secundaria predominaron las infecciones, y los tratamientos más usado fueron los antiinflamatorios no esteroideos. Conclusiones: se trata de una importante enfermedad de salud, cuyo un diagnóstico etiológico temprano permite un tratamiento adecuado. Resulta difícil su identificación y manejo tanto en la atención primaria como en la secundaria (AU).

ABSTRACT Introduction: erythema nodosum is the most common clinical-pathological variant of panniculitis. It is an immunological skin reaction in response to a wide spectrum of etiologic agents. Objective: to characterize the clinical-epidemiological behavior of erythema nodosum. Materials and methods: a descriptive, prospective and longitudinal study was carried out in patients with diagnosis of erythema nodosum, admitted to the Provincial Teaching Clinical Surgical Hospital León Cuervo Rubio, of Pinar del Río, in the period January 2017 to December 2018. The universe was formed by 34 patients with clinical diagnosis of erythema nodosum, hospitalized in the services of Internal Medicine and Dermatology. Medical records, physical examination and laboratory tests were used for the collection of information. Theoretical, empirical and statistical methods were used; descriptive statistics was used through absolute frequencies and percentage. Results: the largest group of patients was between 30 and 39 years, and they were female. Injuries were more frequent in the winter months. The type of idiopathic erythema nodosum prevailed. The time of evolution prevailed from 1 to 3 months. Infections predominated as a secondary cause, and the most commonly used treatments were non-steroidal anti-inflammatory drugs. Conclusions: it is an important health condition, whose early etiological diagnosis allows the proper treatment. Its identification and management in both primary and secondary care is difficult (AU).

A case report and literature review of cutaneous intravascular large B-cell lymphoma presenting clinically as panniculitis: a difficult diagnosis, but a good prognosis,

Abstract Intravascular large B-cell lymphoma is a rare, non-mass-forming, extranodal large B-cell lymphoma subtype characterized by the presence of tumor cells in the lumens of vessels. It is divided into two major types: classical and Asian. Patients presenting only with skin involvement are mostly female, at a younger age than classical intravascular large B-cell lymphoma patients, and have a better prognosis. Since the diagnosis of cases with isolated skin involvement is difficult, keeping this entity in mind, performing a careful microscopic examination, and applying new, effective treatment regimens will make it possible to achieve better clinical outcomes in these cases.

Research Progression of Subcutaneous Panniculitis-like T-Cell Lymphoma--Review / 中国实验血液学杂志

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a very rare cutaneous malignant lymphoma derived from cytotoxic T cells that mainly involves subcutaneous adipose tissue rather than epidermis and dermis. It usually occurs in young and middle-aged population, and the etiology is currently unclear. Clinically, SPTCL is characterized by subcutaneous plaques, nodules, and skin ulcers with swell and ache, mainly presenting in limbs and trunk. SPTCL has been restricted to cases that express α/β phenotype, whereas cases with γ/δ phenotype are categorized to cutaneous γ/δ

Lobular panniculitis of the thigh as the only cutaneous manifestation of reactivation of Chagas disease in a renal transplant patient: a case report

Abstract Reactivation of chronic Trypanosoma cruzi infection in solid organ transplant recipients (SOTRs) has been reported. The patient presented with a 2-week history of two painful erythematous, infiltrated plaques with central ulceration and necrotic crust on the left thigh. She had a history of chronic indeterminate Chagas disease (CD) and had received a kidney transplant before 2 months. Skin biopsies revealed lobular panniculitis with intracellular amastigote forms of T. cruzi. The patient was diagnosed with CD reactivation. Treatment with benznidazole significantly improved her condition. CD reactivation should be suspected in SOTRs living in endemic areas with clinical polymorphism of skin lesions.

Necrosis grasa del recién nacido / Fat necrosis of the newborn

Resumen: Introducción: Las paniculitis constituyen un grupo de enfermedades que afectan al tejido graso subcutáneo y se manifiestan clínicamente como nódulos. Su patogenia no es del todo clara, por lo general es asintomático. El diagnóstico confirmatorio es histológico. Objetivo: describir las características clínicas e histopatológicas de un caso de necrosis grasa, una forma especifica de paniculitis en el recién nacido (RN). Caso Clínico: RN femenino de 40 semanas, parto cesárea de urgencia por taqui cardia fetal más meconio, APGAR 7-8-9. Requirió oxigeno y presión positiva por 5 min. Al quinto día de vida presentó aumento de volumen en tronco posterior, de coloración eritematosa - violácea, remitente a la palpación, no doloroso. Ecotomografría de piel y partes blandas informó aumento de la ecogenecidad del tejido celular subcutáneo y pérdida de definición de las celdillas adiposas de aproximadamente 42.3 x 9.7 x 20.1 mm, sin presencia de vascularización. Biopsia de piel: epidermis con acantosis irregular y ortoqueratosis en cestas; dermis papilar con infiltrado inflamatorio y dermis reticular y tejido adiposo con presencia de infiltrado linfohistocitiario con tendencia a la formación de nódulos, sin compromiso vascular, leves depósitos de colesterol; compatible con necrosis grasa del recién nacido (NGRN). Paciente tuvo regresión completa de la lesión a los tres meses de vida. Conclusiones: se describe un caso compatible clínica e histológicamente con NGRN; sin complica ciones durante su observación. Por lo general esta patología tiene buen pronóstico, con resolución espontánea, como en nuestro caso.

Abstract: Introduction: Panniculitis is a group of diseases that affect subcutaneous fat tissue and clinically manifest as nodules. Its pathogenesis is not entirely clear, and it is usually asymptomatic. The confirma tory diagnosis is histological. Objective: To describe the clinical and histopathological characteristics of a case of fat necrosis, a specific form of panniculitis in the newborn (NB). Clinical Case: 40-week female NB, born by emergency cesarean section due to fetal tachycardia with meconium, Apgar score 7-8-9. She required oxygen and positive pressure for five minutes. On the fifth day of life, she presen ted an increased volume in the posterior trunk region, with an erythematous - purplish discoloration, which is soft and non-tender to palpation. Skin and soft tissues ultrasound showed increased echo genicity of the subcutaneous cellular tissue and loss of definition of the adipocytes of 42.3 x 9.7 x 20.1 mm approximately, without vascularization. Skin biopsy showed epidermis with irregular acanthosis and basket-weave orthokeratosis; papillary dermis with inflammatory infiltrate, and reticular dermis and adipose tissue with presence of lymphohistiocytic infiltrate with a tendency to form nodules, without vascular involvement, and small cholesterol deposits, compatible with subcutaneous fat ne crosis (SBFN) of the newborn. The patient at three months of age had complete regression of the lesion. Conclusions: a clinically and histologically compatible case with SBFN is described, that did not present complications during observation. In general, this pathology has a good prognosis, with spontaneous resolution as in our case.

Eritema nodoso asociado al uso de anillo vaginal anticonceptivo / Erythema nodosum associated with the use of contraceptive vaginal ring

El eritema nodoso (EN) es la forma de paniculitis más común. Este trastorno representa una reacción de hipersensibilidad frente a diferentes antígenos, así como múltiples enfermedades sistémicas y fármacos, aunque en la mayoría de casos se desconoce la causa. Nuevos fármacos se añaden a la lista de involucrados en la etiopatogenia del eritema nodoso conforme van pasando los años, siendo uno de ellos los anticonceptivos hormonales orales combinados. El objetivo de este trabajo es proponer una relación entre los estrógenos de cualquier método anticonceptivo como puede ser el anillo vaginal combinado y la aparición del eritema nodoso.

Erythema nodosum (EN) is the most common form of panniculitis. This disorder represents a hypersensitivity reaction in front of different antigens, as well as multiple systemic diseases and drugs, although in most cases the cause is unknown. New drugs are added to the list of those involved in the etiopathogenesis of erythema nodosum as the years go by, one of them being combined oral hormonal contraceptives. The objective of this study is to propose a relationship between estrogens from any contraceptive method such as the combined vaginal ring and the appearance of erythema nodosum.

Paniculitis secundaria a terapia target en paciente con melanoma, lo que el dermatólogo debe saber: reporte de un caso / Panniculitis in association with target therapy in melanoma patient, what the dermatologist should know: a case report

Las terapias target constituyen hoy en día una alternativa terapéutica cada vez más utilizada para el manejo de pacientes con melanoma metastásico. Sin embargo, se han descrito múltiples efectos farmacológicos adversos asociados a su uso, siendo los cutáneos los de mayor prevalencia. Se presenta el caso de un hombre de 55 años con diagnóstico de melanoma cutáneo metastásico etapa IV, BRAFV600E mutado, en tratamiento con dabrafenib/trametinib que consultó por desarrollo de lesiones nodulares eritematosas sensibles en extremidades superiores e inferiores, asociadas a sensación febril durante el curso del tratamiento. Se descartó alguna infección sobreagregada. Se realizó una biopsia de las lesiones cutáneas, con confirmación diagnóstica histopatológica de una paniculitis mixta de predominio septal, granulomatosa y con vasculitis leucocitoclástica. La paniculitis asociada a esta terapia ha sido descrita en la literatura y se ha considerado un efecto farmacológico inmunomediado adverso, relacionándose a un mejor pronóstico para el melanoma metastásico en tratamiento. Por lo tanto, así como en el caso presentado, se evita la suspensión del fármaco y se asocia terapia sintomática en caso de mayores molestias del paciente. Es de alta relevancia para el dermatólogo conocer e interpretar adecuadamente este efecto adverso farmacológico, y así indicar el manejo más adecuado para el paciente.

Target therapies are currently a therapeutic option increasingly used for the management of patients with metastatic melanoma. However, there are multiple adverse pharmacological effects associated with their use that have been described. Cutaneous adverse reactions are the most frequent. We report the case of a 55-year-old man with a diagnosis of stage IV BRAFV600E-mutated metastatic cutaneous melanoma undergoing treatment with dabrafenib/trametinib, who consulted due to the development of erythematous nodular lesions in the upper and lower limbs associated with febrile sensation during the course of treatment. Infection was ruled out and a biopsy of the skin lesions was done, which provided the histopathological confirmation of a predominantly septal, granulomatous with leukocytoclastic vasculitis, mixed panniculitis. Panniculitis associated with this therapy has been described in the literature and has been considered an immune-mediated pharmacological adverse effect. It is considered to be related to a better prognosis in the treatment of metastatic melanoma. Consequently, as shown in this case report, target therapy should not be discontinued and symptomatic medication should be given to alleviate patient discomfort. The dermatologist should know and properly interpret this adverse effect and prescribe the most appropriate management for the patient.

Paniculectomía masiva, cirugía funcional para pacientes con panniculus morbidus / Massive panniculectomy, a functional surgery for patients with panniculus morbidus

Panniculus morbidus es una enfermedad asociada a la obesidad mórbida que genera problemas higiénicos y discapacidad funcional. La paniculectomía masiva conlleva varias complicaciones, sin embargo, permite restaurar la calidad de vida y funcionalidad del paciente convirtiéndose así en un reto para el cirujano en su planificación, ejecución y manejo peri operatorio y más aún si no se tienen los medios. Es por ello que esta serie de casos tiene como objetivo presentar nuestra experiencia quirúrgica en el manejo de pacientes con obesidad mórbida sometidos a paniculectomía funcional con resultados satisfactorios. Desde nuestra experiencia en el abordaje de estos pacientes destacamos que la ausencia de materiales de suspensión no imposibilita llevar a cabo la cirugía con resultados aceptables siempre y cuando se tomen en cuenta los conceptos de resección y síntesis de la pared abdominal.(AU)

Panniculus morbidus is a disease associated with morbid obesity that generates hygienic problems and functional disability. Massive panniculectomy involves several complications, however, it allows restoring the patient's quality of life and functionality, thus becoming a challenge for the surgeon in his planning, execution and perioperative management and even more if the materials are not available. That is why this case series aims to present our surgical experience in the management of morbidly obese patients undergoing functional panniculectomy with satisfactory results. From our experience in the approach of these patients, we highlight that the absence of suspension materials does not make it impossible to carry out the surgery with acceptable results as long as the concepts of resection and synthesis of the abdominal wall were taken into account.(AU)

Vulvitis migratoria causada por gnatostomiasis importada / Migratory vulvitis caused by imported gnathostomiasis

Resumen La gnatostomiasis es una parasitosis emergente en países no endémicos. Este nematodo zoonótico requiere de agua dulce para su ciclo de vida, donde sus larvas se enquistan principalmente en peces. La migración subcutánea de las larvas produce habitualmente una paniculitis eosinofílica de rápido avance. Se describe un caso clínico de un paciente con una lesión migratoria, sin mejoría clínica con terapia antibacteriana. La búsqueda de factores de riesgo, sumado a la evolución y a los hallazgos de laboratorio hizo sospechar el diagnóstico. La gnatostomiasis debe ser sospechado en pacientes con lesiones de piel migratorias, que han consumido pescado crudo durante viajes a países endémicos en Sudamérica o Asia.

Gnathostomiasis is an emerging disease in non-endemic countries. This zoonotic nematode requires aquatic freshwater environments to complete its life cycle where larvae get encrusted in fishes. Typically, the infection manifests as migratory subcutaneous lesion caused by the larvae trak, which produces an eosinophilic panniculitis. Here we describe a patient who presented a migratory lesion with no response to antimicrobial therapy, a careful travel and food history together with specific laboratory tests led to the correct diagnosis. Gnathostomiasis should be suspected in patients with migratory skin lesions who have consumed raw freshwater fish during travel to endemic countries in South America or Asia.

Histoplasma panniculitis in a patient with systemic lupus erythematosus

Abstract: Histoplasmosis usually presents primarily as lung infection. Occasionally, mainly in immunocompromised hosts, it can spread and cause systemic manifestations. Skin lesions have been reported in 10 to 15 percent of cases of disseminated histoplasmosis, and panniculitis has been described as an unusual form of presentation in affected patients. We present the case of a patient with systemic lupus erythematosus who presented cellulitis due to disseminated histoplasmosis.

Pancreatitis, Panniculitis, and Polyarthritis Syndrome Simulating Cellulitis and Gouty Arthritis / 대한소화기병학회잡지

Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome is a rare but critical disease with a high mortality rate. The diagnostic dilemma of PPP syndrome is the fact that symptoms occur unexpectedly. A 48-year-old man presented with fever and painful swelling of the left foot that was initially mistaken for cellulitis and gouty arthritis. The diagnosis of PPP syndrome was made based on the abdominal CT findings and elevated pancreatic enzyme levels, lobular panniculitis with ghost cells on a skin biopsy, and polyarthritis on a bone scan. The pancreatitis and panniculitis disappeared spontaneously over time, but the polyarthritis followed its own course despite the use of anti-inflammatory agents. In addition to this case, 30 cases of PPP syndrome in the English literature were reviewed. Most of the patients had initial symptoms other than abdominal pain, leading to misdiagnosis. About one-third of them were finally diagnosed with a pancreatic tumor, of which pancreatic acinar cell carcinoma was the most dominant. They showed a mortality rate of 32.3%, associated mainly with the pancreatic malignancy. Therefore, PPP syndrome should be considered when cutaneous or osteoarticular manifestations occur in patients with pancreatitis. Active investigation and continued observations are needed for patients suspected of PPP syndrome.

Pancreatitis, Panniculitis, and Polyarthritis Syndrome Simulating Cellulitis and Gouty Arthritis / 대한소화기학회지

Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome is a rare but critical disease with a high mortality rate. The diagnostic dilemma of PPP syndrome is the fact that symptoms occur unexpectedly. A 48-year-old man presented with fever and painful swelling of the left foot that was initially mistaken for cellulitis and gouty arthritis. The diagnosis of PPP syndrome was made based on the abdominal CT findings and elevated pancreatic enzyme levels, lobular panniculitis with ghost cells on a skin biopsy, and polyarthritis on a bone scan. The pancreatitis and panniculitis disappeared spontaneously over time, but the polyarthritis followed its own course despite the use of anti-inflammatory agents. In addition to this case, 30 cases of PPP syndrome in the English literature were reviewed. Most of the patients had initial symptoms other than abdominal pain, leading to misdiagnosis. About one-third of them were finally diagnosed with a pancreatic tumor, of which pancreatic acinar cell carcinoma was the most dominant. They showed a mortality rate of 32.3%, associated mainly with the pancreatic malignancy. Therefore, PPP syndrome should be considered when cutaneous or osteoarticular manifestations occur in patients with pancreatitis. Active investigation and continued observations are needed for patients suspected of PPP syndrome.

Oxandrolona no tratamento da lipodermatoesclerose: relato de caso / Oxandrolone for treatment of lipodermatosclerosis: case report

A lipodermatoesclerose é uma paniculite que se caracteriza por endurecimento e hiperpigmentação da pele envolvendo as panturrilhas, com a aparência de "garrafa de champanhe invertida". Muitas abordagens terapêuticas têm sido recomendadas, mas o uso de oxandrolona para essa finalidade foi pouco estudado até o momento. Relatamos um caso de lipodermatoesclerose aguda em uma mulher de 61 anos, com história prévia de tratamento cirúrgico para insuficiência venosa de membros inferiores. A paciente apresentava edema e lesões dolorosas e eritematosas com infiltração difusa, que acometiam principalmente a face posterior da panturrilha esquerda. Foi tratada inicialmente com estanozolol e pentoxifilina, com boa resposta. Devido à indisponibilidade do estanozolol, iniciou-se o uso de oxandrolona. Esse tratamento foi bem tolerado, resultando em redução significativa do edema, do eritema e da infiltração presentes nos membros inferiores, além de alívio da dor. A oxandrolona pode representar uma opção útil e segura no tratamento da lipodermatoesclerose aguda

Lipodermatosclerosis is a panniculitis characterized by hardening and hyperpigmentation of the skin involving the calves with an "inverted champagne bottle" appearance. Many therapeutic approaches have been recommended, but the use of oxandrolone for this purpose has been studied very little to date. We report a case of acute lipodermatosclerosis in a 61-year-old woman with a previous history of surgical treatment for venous insufficiency of the lower limbs. The patient presented with edema and painful, erythematous lesions with diffuse infiltration, mainly affecting the posterior aspect of the left calf. She was initially treated with stanozolol and pentoxifylline, with good response. Due to unavailability of stanozolol, she was put on oxandrolone. This treatment was well tolerated, reduced the intensity of edema, erythema, and infiltration in the lower limbs, effectively leading to pain relief. Oxandrolone may be a useful and safe treatment for patients with acute lipodermatosclerosis

Subcutaneous fat necrosis of the newborn: clinical and histopathological correlation

Abstract: Subcutaneous fat necrosis of the newborn is a rare benign panniculitis found in term and post-term neonates. Diagnosis is based on clinical characteristics and specific alterations in the adipocytes, detected by anatomical pathology. Subcutaneous fat necrosis of the newborn can occur in uncomplicated pregnancy and childbirth. However, perinatal complications such as asphyxia, hypothermia, seizures, preeclampsia, meconium aspiration, and even whole-body cooling used in newborns with perinatal hypoxia/anoxia may be associated with this entity.

Oligoartritis, paniculitis y pioderma gangrenoso como manifestaciones de un Linfoma no Hodgkin / Oligoarthritis, panniculitis and pyoderma gangrenosum associated with non-Hodgkin lymphoma: report of one case

An assortment of clinical and laboratory abnormalities may occur as paraneoplastic syndromes in lymphomas. Rheumatological and dermatological manifestations such as paraneoplastic arthritis and pyoderma gangrenosum must be underscored. We report a 28 years old woman who developed pyoderma gangrenosum and two years later presented with arthritis of knees and ankles associated with panniculitis interpreted as erythema induratum that was pathologically confirmed. She developed a reactivation of pyoderma gangrenosum, that was refractory to treatment. Complementary studies showed a pulmonary nodule and a right paravertebral mass with involvement of the psoas muscle. Biopsies of both masses and a new pathological skin study demonstrated a large B-cell non-Hodgkin's lymphoma.

Panniculitis associated with amyopathic dermatomyositis

Abstract: Panniculitis is a rare clinical finding in dermatomyositis, with less than 30 cases reported and there is only one case associated with the amyopathic subtype described in the literature. The present report describes a 49-year-old female patient that one year after being diagnosed with amyopathic dermatomyositis, presented indurated, painful, erythematous to violaceous nodules located on the upper limbs, thighs and gluteal region. Skin biopsy revealed lobular panniculitis with a lymphocytic infiltrate. The patient was treated with prednisone and methotrexate, but remained unresponsive to treatment.

Monogenic Autoimmune Diseases

Monogenic autoimmune diseases (AD) present as lupus-like clinical manifestations with recurrent fever or various vasculopathies. Recurrent fever with an elevation of acute phase reactants and various skin lesions are similar in monogenic AD and autoinflammatory disease. The molecular pathogenesis of adult systemic erythematosus can be understood through monogenic AD based on gene defects: complement, apoptosis, interferonopathy via nucleic acid sensing, tolerance, rasopathies, and others. Skin vasculopathy with chilblains and livedo reticularis, interstitial lung disease, and panniculitis are common occurrences in type I interferonopathy. Some syndromes have been reported to present with autoimmune inflammation and the general clinical findings, including cerebral calcification. Various clinical manifestations in monogenic AD present in accordance with the gene loss- or gain-of-function mutations involved. The monogenic AD for the early onset of more severe lupus-like symptoms or vasculopathy needs to be considered. Furthermore, clinical trials were conducted via targeted therapy for related molecular pathways, because conventional treatments were not effective in managing monogenic AD.