Necrolytic migratory erythema: dyskeratotic dermatitis, a clue to early diagnosis

Necrolytic Migratory Erythema: Case Report and Clinical Review

Background:

Necrolytic Migratory Erythema (NME) is a rarely encountered dermatologic condition. It is the characteristic feature of a paraneoplastic syndrome associated with neuroendocrine pancreatic tumors. A case of NME initially diagnosed and treated as psoriasis is reviewed. A review of the current literature regarding NME is also included.

Objective:

The purpose of this report is to familiarize dermatologists with a rare and potentially fatal disorder. Early recognition of NME can lead to possible cure, while delayed identification of the disease is associated with metastatic disease and a poor prognosis for the patient.

Conclusion:

When evaluating the patient who presents with a dermatitis and weight loss, it is important to exercise great caution. The differential diagnosis should be reevaluated in a disease that is not responsive to first-line therapy before further treatment is considered.

[Necrolytic migratory erythema associated with glucagonoma]

Glucagonoma is a rare pancreatic tumor that is usually associated with a syndrome that includes diabetes, anemia, weight loss and skin lesions in the form of necrolytic migratory erythema. We present the case of a patient with malignant glucagonoma treated with surgery and octreotide, which manifested with skin lesions. The discussion will review the physiopathology, other causes of necrolytic erythema, diagnosis and differential diagnosis and treatment.

Necrolytic migratory erythema

BACKGROUND

Necrolytic migratory erythema is considered to be a paraneoplastic dermatosis. The classical symptoms are associated with alpha-cell pancreatic islet cell tumor or 'glucagonoma'. Generally, extracutaneous hallmarks of this disease include weight loss, diabetes, anaemia and diarrhoea.

OBSERVATION

We report a case of a 39-year-old woman with a 3-year history of recalcitrant psoriasiform eruption, who had no other associated symptoms on routine examination. Histologic examinations suggested necrolytic migratory erythema. Abdominal computer tomography was performed, which revealed a tumor in the tail of the pancreas. After distal resection of the pancreas her skin symptoms resolved in a few days time. Histology was consistent with glucagonoma. She is clinically well and symptomless and no signs of metastasis after 4 years.

CONCLUSIONS

It is infrequent to have only necrolytic migratory erythema, hyperglucagonaemia and islet-cell tumor but no other extracutaneous symptoms in glucagonoma syndrome. To our knowledge, ours is the second such case reported in the literature. Skin symptoms are important, often they are the clue to the diagnosis of glucagonoma syndrome.

Necrolytic migratory erythema: clinicopathologic study of 13 cases

BACKGROUND

The clinical mucocutaneous manifestations of glucagonoma syndrome are recognized easily when they occur in the classic pattern of acral or periorificial lesions evolving in recurrent crops, with an annular and migratory distribution, in a patient with diabetes mellitus who has had recent weight loss and anemia. Not infrequently, noncharacteristic clinical and histopathologic features are observed and, in these cases, the diagnosis of pancreatic neoplasm may be delayed.

AIM

To review the clinical and histopathologic features of cutaneous manifestations of glucagonoma syndrome.

METHODS

The clinicopathologic features of 13 patients (eight women) with widespread or localized cutaneous eruption as a manifestation of islet cell pancreatic carcinoma with marked glucagon secretion (glucagonoma) were reviewed.

RESULTS

The definitive diagnosis of the cutaneous eruption was established at the time of diagnosis of the pancreatic neoplasm (three patients) or afterwards (10 patients). In nine patients, the mucocutaneous manifestations preceded the diagnosis of the pancreatic neoplasm by 1 month to 3 years (mean, 12 months). In only eight biopsy specimens were the histopathologic features considered to be suggestive or characteristic of necrolytic migratory erythema. Diffuse parakeratosis, that occasionally arose abruptly from normal epidermis, was observed in 12 biopsy specimens. By the time necrolytic migratory erythema was diagnosed, the pancreatic carcinoma had metastasized to the liver, regional lymph nodes, or bone in 12 patients.

CONCLUSION

Increased awareness of the polymorphic mucocutaneous and nonspecific histopathologic features of glucagonoma syndrome is needed to avoid unnecessary delay in the diagnosis of this syndrome.

The glucagonoma syndrome: a review of its features and discussion of new perspectives

Glucagonoma syndrome is a paraneoplastic phenomenon characterized by an islet alpha-cell pancreatic tumor, necrolytic migratory erythema, diabetes mellitus, weight loss, anemia, stomatitis, thromboembolism, and gastrointestinal and neuropsychiatric disturbances. These clinical findings in association with hyperglucagonemia and demonstrable pancreatic tumor establish the diagnosis. Glucagon itself is responsible for most of the observed signs and symptoms, and its induction of hypoaminoacidemia is thought to lead to necrolytic migratory erythema. Liver disease and fatty acid and zinc deficiency states may also contribute to the pathogenesis of the eruption in some cases. Most patients are diagnosed too late in the clinical course for cure, but successful palliation of symptomatology can usually be achieved with surgical and medical intervention. This paper reviews the glucagonoma syndrome, paying particular attention to its cutaneous features, and provides new perspectives in our current understanding of this phenomenon.

Suspected necrolytic migratory erythema associated with chronic hepatopathy in a cat

A cat presenting with generalised hypotrichosis and crusts on the feet and tail was found to have an unusual chronic hepatopathy. There was also evidence of a chronic small intestinal disease which went undiagnosed. Necrolytic migratory erythema was suspected based on clinical findings and dermatohistopathology, and an association with the chronic hepatopathy was suggested. This is the first report of such an association in a cat. Serum zinc, amino acids and essential fatty acids were analysed, and medical treatment was given with equivocal efficacy.

Rapid resolution of necrolytic migratory erythema after glucagonoma resection

A 55-year-old man presented with an 11-year history of necrolytic migratory erythema and glossitis. After the patient's serum glucagon was demonstrated to be elevated, computed tomography scan revealed a mass involving the head of the pancreas. The patient underwent a Whipple-type pancreatico-duodenectomy and his rash resolved completely 6 days after tumor resection. He received no adjuvant treatment. A discussion of the varying theories regarding the pathogenesis and treatment of glucagon-associated necrolytic migratory erythema is presented.

The glucagonoma syndrome. Clinical and pathologic features in 21 patients

The glucagonoma syndrome is a rare disorder characterized by weight loss, necrolytic migratory erythema (NME), diabetes, stomatitis, and diarrhea. We identified 21 patients with the glucagonoma syndrome evaluated at the Mayo Clinic from 1975 to 1991. Although NME and diabetes help identify patients with glucagonomas, other manifestations of malignant disease often lead to the diagnosis. If the diagnosis is made after the tumor is metastatic, the potential for cure is limited. The most common presenting symptoms of the glucagonoma syndrome were weight loss (71%), NME (67%), diabetes mellitus (38%), cheilosis or stomatitis (29%), and diarrhea (29%). Although only 8 of the 21 patients had diabetes at presentation, diabetes eventually developed in 16 patients, 75% of whom required insulin therapy. Symptoms other than NME or diabetes mellitus led to the diagnosis of an islet cell tumor in 7 patients. The combination of NME and diabetes mellitus led to a more rapid diagnosis (7 months) than either symptom alone (4 years). Ten patients had diabetes mellitus before the onset of NME. No patients had NME clearly preceding diabetes mellitus. Increased levels of secondary hormones, such as gastrin (4 patients), vasoactive intestinal peptide (1 patient), serotonin (5 patients), insulin (6 patients, clinically significant in 1 only), human pancreatic polypeptide (2 patients), calcitonin (2 patients) and adrenocorticotropic hormone (2 patients), contributed to clinical symptoms leading to the diagnosis of an islet cell tumor before the onset of the full glucagonoma syndrome in 2 patients. All patients had metastatic disease at presentation. Surgical debulking, chemotherapy, somatostatin, and hepatic artery embolization offered palliation of NME, diabetes, weight loss, and diarrhea. Despite the malignant potential of the glucagonomas, only 9 of 21 patients had tumor-related deaths, occurring an average of 4.91 years after diagnosis. Twelve patients were still alive, with an average age follow-up of 3.67 years.

Necrolytic migratory erythema without glucagonoma in patients with liver disease

BACKGROUND

Necrolytic migratory erythema (NME) is an uncommon inflammatory dermatosis with a distinct clinical and histologic appearance. NME is usually associated with glucagonoma. Only a few cases of NME in the absence of glucagonoma have been previously reported.

OBJECTIVE

We sought to understand further the pathogenesis of NME by analyzing data from three patients.

METHODS

Three patients were examined both clinically and histopathologically.

RESULTS

Each patient had an extensive erythematous scaling eruption in intertriginous, perioral, and acral areas, and a markedly red, smooth tongue. Skin biopsy specimens showed confluent parakeratosis, epidermal pallor, papillary edema, and a lymphohistiocytic infiltrate. Two patients had alcoholic liver disease and one had liver dysfunction as a result of hemochromatosis. Serum albumin level was depressed, and liver enzyme values were increased in all three patients. Glucagonoma was undetectable in these patients.

CONCLUSION

In the absence of glucagonoma, hepatocellular dysfunction and hypoalbuminemia appear to be the most common factors associated with NME.

Suprabasal acantholysis--an unusual feature of necrolytic migratory erythema

A 67-year-old man with diabetes, weight loss and anaemia initially presented with a widespread scaling erythematous rash; a skin biopsy demonstrated marked suprabasal acantholysis. A subsequent biopsy showed localized upper epidermal necrolysis and the diagnosis of glucagonoma syndrome was later confirmed. Glucagonoma syndrome should be considered in patients with diabetes, weight loss and anaemia who present with a scaling rash, the histology of which shows suprabasal acantholysis. The extent of any upper epidermal necrolysis may be be very limited.