Acute Recurrent Exacerbations of Mesenteric Panniculitis With Immunosuppressive Therapy: A Case Report and a Brief Review.

Mesenteric panniculitis (MP) is a rare, benign, and idiopathic disorder characterized by chronic inflammation of the mesenteric adipose tissue of the small intestine. The exact etiology of MP is unknown and its associations with underlying malignancies continues to be poorly understood. In this case report, we describe a rare case of acute exacerbations of MP in a middle-age female with a known past medical history of non-Hodgkin's lymphoma in remission and small bowel resection for a localized carcinoid tumor. The patient was diagnosed with MP 4 years ago and started on tamoxifen therapy with adequate control of her symptoms. Last year, she reported to the emergency department with multiple episodes of sudden-onset, severe, and localized right upper quadrant abdominal pain and nausea without vomiting. She was diagnosed with an acute exacerbation of MP and a decision was made to add 60 mg prednisone daily in addition to her tamoxifen regimen. She remained symptomatically stable for the next 6 months after the start of dual therapy with tamoxifen and prednisone. However, for the past 6 months, the patient reported to the emergency department on an average of 2 times/month with the same recurrent symptoms despite high compliance with tamoxifen and prednisone therapy. She was admitted for her pain management and her dose of prednisone was increased and she was subsequently discharged home with improvement of her symptoms. Her tamoxifen was switched to mycophenolate on her follow-up visit with gastrointestinal clinic, and her disease has remained stable for the past 2 months. Our case report discusses in-depth the literature on MP and its management. We also detail the steps in management of a rare case of recurrent acute exacerbations of MP despite the patient being on immunosuppressive therapy.

Lesser Omental Panniculitis.

A 44-year-old woman presented to our hospital with abdominal pain. Abdominal ultrasonography and computed tomography showed a mass-like change in the lesser omentum between the liver and stomach. Esophagogastroduodenoscopy revealed a submucosal tumor-like change, and endoscopic ultrasonography (EUS) revealed that the mass was located outside of the stomach wall. We performed EUS fine-needle aspiration and diagnosed panniculitis of the lesser omentum. Based on these findings, we suggest that mass-like lesions in the lesser omentum and submucosal tumor-like changes in the anterior wall on the lesser curvature side of the stomach be evaluated for the possibility of panniculitis of the lesser omentum.

Duplex Doppler Sonographic Assessment of the Superior Mesenteric Artery in Patients With Mesenteric Panniculitis.

OBJECTIVES: We aimed to determine how the hemodynamic parameters of the superior mesenteric artery are affected in mesenteric panniculitis. METHODS: Twenty-one patients with a diagnosis of mesenteric panniculitis on computed tomography were evaluated with duplex Doppler sonography. The control group consisted 20 asymptomatic volunteers. The peak systolic velocity, end-diastolic velocity (EDV), resistive index (RI), pulsatility index (PI), blood flow volume, and body mass index were measured in the group of patients with mesenteric panniculitis, and the findings were compared with those of the control group. RESULTS: The mean blood flow volume and EDV were significantly higher in the patient group: The mean superior mesenteric artery blood flow volume ± SD was 917.86 ± 228.97 mL/min in the patient group versus 389.73 ± 92.72 mL/min in the control group (P < .001). The mean EDV was 31.56 ± 8.44 m/s in the patient group versus 19.27 ± 4.19 m/s in the control group (P < .001). The mean RI and PI were significantly lower in the patient group: The mean RI was 0.81 ± 0.04 in the patient group versus 0.85 ± 0.03 in the control group (P = .001). The mean PI was 2.69 ± 0.68 in the patient group versus 3.81 ± 1.13 in the control group (P = .001). the mean superior mesenteric artery diameter was 7.30 ± 0.67 mm in the patient group versus and 6.46 ± 0.66 mm in the control group (P < .001). The mean BMI was 27.95 ± 3.80 kg/m2 in the patient group versus 23.16 ± 3.47 kg/m2 in the control group (P < .001). CONCLUSIONS: In patients with mesenteric panniculitis, the Doppler spectrum of the superior mesenteric artery shows detectable changes, which are characterized by decreased vascular resistance and increased blood flow.

An Overlooked Potentially Treatable Disorder: Idiopathic Mesenteric Panniculitis.

OBJECTIVE: The aim of this study was to determine the prevalence of mesenteric panniculitis (MP) and to describe its clinical characteristics, therapy, and outcome. SUBJECTS AND METHODS: This retrospective study was carried out among patients with MP based on computed tomography (CT) scans from January 2012 to December 2015. The CT images were reanalyzed by study radiologists to confirm the previous MP diagnosis. Patients were divided into 2 groups, i.e., idiopathic and secondary, based on the presence or absence of associated predisposing factors such as trauma, malignancy, autoimmune disorders, ischemia, or previous abdominal surgery. The clinical characteristics of the 2 groups, as well as treatments, were assessed. RESULTS: Among the 19,869 CT scans, 36 patients (0.18%) with MP were identified (i.e., 19 [53%] females and 17 [47%] males). The median age was 54 years (range 26 - 76). Twenty-four patients (67%) were categorized into the idiopathic group. Malignancy was the predisposing factor in 8 (22%) of those patients. Furthermore, abdominal pain was the cardinal symptom observed in 22 patients (92%) in the idiopathic group. In the idiopathic group, 15 patients (63%) were treated with antibiotics and 16 (67%) were treated with nonsteroidal anti-inflammatory drugs (NSAID). One unresponsive patient was treated with colchicine. Symptomatic relief was achieved in all of the treated patients. CONCLUSION: In this study, a symptomatic idiopathic subgroup of patients with MP did not have any associated disorder. The response to treatment with antibiotics and NSAID was effective in most of the patients. Based on these findings, anti-inflammatory treatments beyond NSAID and surgery should be reserved for patients who are unresponsive to antibiotics and NSAID.

Estudio prospectivo para determinar el valor real de la captación de 18F-FDG mesentérica en pacientes oncológicos: ¿paniculitis mesentérica inflamatoria o tumoral? / A prospective study to determine the real value of mesenteric 18F-FDG uptake in cancer patients. inflammatory or tumoral mesenteric paniculitis?

Objetivo. Determinar el comportamiento metabólico de la paniculitis mesentérica (PM), los posibles patrones de presentación en la imagen 18F-FDG-PET/TAC y conocer si es una técnica diagnóstica fiable para diferenciar enfermedad tumoral y patología inflamatoria en este contexto. Material y métodos. Dos mil seiscientas sesenta y seis exploraciones PET/TAC fueron evaluadas de forma prospectiva desde abril de 2012 hasta agosto de 2013. Se incluyeron en nuestro estudio a 30 pacientes (37 exploraciones) que presentaban signos radiológicos de PM, 8 mujeres y 22 hombres, con edades comprendidas entre 39 y 81 años. Según la captación de 18F-FDG en las lesiones mesentéricas, expresado como SUVmax, los pacientes fueron clasificados en dos grupos: Grupo A: conformado por 10 pacientes con captación aumentada, SUVmax ≥ 2 o superior a la actividad hallada en el tejido mesentérico sano circundante y Grupo B (conformado por 20 pacientes): SUVmax < 2 o indistinguible del tejido sano. Resultados. En el 80% de los pacientes del Grupo A (media de SUVmax 7,11) no se demostraron criterios de afectación tumoral mesentérica durante un seguimiento medio de 13 meses (falsos positivos), exceptuando a dos pacientes de este grupo que sí mostraron signos de afectación tumoral (SUVmax 7,57 y 9,46), obteniéndose un valor predictivo positivo de 49,79%. En el 100% de los pacientes del Grupo B se confirmó ausencia de afectación tumoral mesentérica. Conclusiones. Ante la presencia de signos radiológicos de PM, un aumento del metabolismo glucídico, incluso intenso y focal en estas lesiones, aunque no excluye la posibilidad de afectación tumoral, puede corresponder, con una alta probabilidad, a actividad inflamatoria (AU)

Aim. To assess the metabolic behavior of mesenteric panniculitis (MP), possible manifestation patterns in 18F-FDG PET/CT imaging and to discover if it is a reliable diagnostic method to differentiate tumor disease from inflammatory condition in this context. Material and methods. A total of 2,666 PET/CT scans were evaluated prospectively from April 2012 to August 2013. Thirty patients were included (37 scans) with radiological signs of MP. There were 8 women and 22 men, aged between 39 and 81 years, in the sample. According to the 18F-FDG uptake in the mesenteric lesions, expressed as SUVmax, patients were classified into two different groups: Group A consisted of 10 patients with increased uptake, SUVmax ≥ 2 or greater than the activity found in the surrounding healthy mesenteric tissue, and Group B (20 patients) SUVmax < 2 or indistinguishable from healthy tissue. Results. No signs of mesenteric tumour involvement were demonstrated during a mean follow up of 13 months (false positives) in 80% of the Group A patients (mean SUVmax 7.11). Signs of the presence of tumor were only demonstrated in two patients of Group A (SUVmax 7.57 and 9.46) with a positive predictive value of 49.79%. All Group B patients were confirmed to be free of mesenteric involvement. Conclusions. The presence of radiological signs of suggestive of MP, increase in glycidic metabolism, even intense and focal in these lesions, which may not exclude the possibility of an ongoing tumour process, would have a high likelihood of being indicative of intense inflammatory activity (AU)

A case of IgG4-related sclerosing mesenteritis.

IgG4-related disease has been recognized as a systemic syndrome characterized by mass-forming lesions with lymphoplasmacytic infiltration and sclerosis. This disease has been identified in various sites, including the pancreas, retroperitoneum, lung, head, and neck. Herein we report a case of IgG4-related sclerosing mesenteritis. An 82-year-old woman was admitted to our hospital due to persistent abdominal pain. Abdominal computed tomography demonstrated a solitary mass with a maximal diameter of 11.7cm in mesentrium of the small intestine. On her laboratory examination, only C-reactive protein level was elevated. Although the pre-operative diagnosis was indefinite, she underwent ileocecectomy. Grossly, an elastic soft mass with foci of hemorrhage was seen in the mesentrium. Microscopically, the lesion was composed of fibroblastic or myofibroblastic spindle cells with abundant stromal fibrosis and inflammatory infiltrate, such as lymphocytes and plasma cells accompanied by lymphoid follicles with a germinal center. Obstructive phlebitis was observed. Immunohistochemically, numerous IgG4-positive plasma cells were observed, and the IgG4/IgG ratio was 75.9%. The serum level of IgG4 examined at post-operation was high. These findings suggested that this lesion was consistent with IgG4-related sclerosing mesenteritis.

Mesenteric panniculitis: various presentations and treatment regimens.

Mesenteric panniculitis is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small intestine and colon. The specific etiology of the disease is unknown. The diagnosis is suggested by computed tomography and is usually confirmed by surgical biopsies. Treatment is empirical and based on a few selected drugs. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. We report two cases of mesenteric panniculitis with two different presentations and subsequently varying treatment regimens. Adequate response was obtained in both patients. We present details of these cases as well as a literature review to compare various presentations, etiologies and potential treatment modalities.

Paniculitis mediastínica / Mediastinal Panniculitis

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Presentación inusual de paniculitis mesentérica / Inusual presentation of mesenteric panniculitis

neoplásico, que afecta al tejido adiposo del mesenterio fundamentalmente. Están descritas varias formas de presentación clínica, desde asintomática hasta dolor abdominal, afectación del estado general y pérdida de peso. Es excepcional que debute como fiebre aislada. En el tratamiento se ha empleado colchicina, dapsona o corticoides asociados o no a inmunosupresores, pero no hay estudios controlados prospectivos que definan el tratamiento adecuado. Además hay casos de regresión sin terapéutica específica. A continuación presentamos el caso de un paciente afecto de paniculitis mesentérica con fiebre de predominio vespertino como única manifestación clínica. El tratamiento médico con corticoides orales, durante 2 años, consiguió la remisión clínica de la enfermedad

Mesenteric Panniculitis is an inflammatory process, not tumoral, of the adipose tissue of the mesentery. There are documented several ways of clinical presentation, from asymptomatic until abdominal pain, affectation of general condition and loose weight. Excepcionally it is declared like only fever. Several treatments have been used, including colchicine, dapsone or corticosteroids associated or not with inmunosupresants, but there are no prospective controlled studies to define appropiate treatment; moreover, there are cases of regresion without specific therapy. Below we present the case of a patient affected for mesenteric panniculitis which the one clinical manifestation is fever predominance evening. The treatment with oral corticosteroids, for 2 years, resulted in the disappearance of the clinica

Mesenteritis retráctil: comunicación de cuatro casos / Retractile mesenteritis: report of 4 cases

Retractile mesenteritis is a rare condition in which the inflammation proces of the mesentery is the characteristic pathological. The histologic changes are variable proportions of fat necrosis, chronic inflammation and fibrosis. The clinical presentation of this process is diverse, also the natural history is variable, ranging from a benign to fatal disease. We reviewed 4 cases of retractile mesenteritis and evaluated the clinical manifestations. There was no gender predominance. The patients aged range was 63-69 years (average 65) Patients more often presented with abdiminal mass (cases n: 1 and n: 4), and chronic diarrhea (cases n: 1 and 3). The etiology is unknown, the treatment is empirical, including corticosteroids, colchicine, immunosuppressive drugs and oral progesterone

Retractile mesenteritis: to treat or not to treat.

Retractile mesenteritis is a rare entity characterized by an inflammatory process of the mesenteric adipose tissue. The disease usually presents with abdominal pain or a palpable abdominal mass. In the majority of cases, the disease is self-limiting and the prognosis is favorable. In this paper we describe a patient who presented with a 7 x 8 cm mass in the left upper abdomen, nausea and pain in the lower back. Symptomatic treatment was given with good result. The literature on different therapeutic intervention is briefly discussed.

[Mesenteric panniculitis: a case of acute and fatal presentation]. / Paniculitis mesentérica: un caso de presentación aguda y fatal?

Mesenteric panniculitis is a rare process in which there is an inflammation of the mesenteric adipose tissue due to unknown causes and mechanisms. It evolves with abdominal pain and/or mass, among other symptoms, generally with a chronic and bening course. The concomitant tests are generally non-specific, the diagnosis being anatompathological. We present the case of an old woman who died hours after starting an episode of abdominal pain. The autopsy showed the presence of mesenteric panniculitis. The sudden onset of the clinical signs, without other justifying cause than the panniculitis itself, suggests that this must be considered in the differential diagnosis of acute abdominal pain. In addition, the absence of other morphological findings which could suggest a fatal cause make us to consider the relationship between this and the panniculitis.

Advanced gastrointestinal malignancy or benign inflammatory disease? An unusual presentation of sclerosing mesenteritis. Report of a case.

The presentation of change of bowel habit, weight loss, muscle wasting, ascites, and the surgical appearance of "omental cake" are almost pathognomonic of advanced gastrointestinal malignancy. In our case, these symptoms represented a unique presentation of the condition sclerosing mesenteritis. Despite its rarity, the clinician should be aware of this "sheep in wolf's clothing," the clinical importance of which lies in the condition's benign and self-limiting course and imparts to the patient a prognosis and treatment that could not be further removed from that of advanced malignancy. Investigations that may be helpful to the surgeon in distinguishing the condition from carcinomatosis and avoiding unnecessary laparotomy include preoperative colonoscopy, barium enema, cytology of any ascites, and intraoperative frozen section biopsy. Treatment of the condition is conservative unless it has caused extrinsic bowel obstruction.