A fatal case of pancreatic panniculitis presenting in a young patient with systemic lupus

Pancreatic panniculitis in active systemic lupus erythematosus

This report documents the case of a 64-year-old African-American female with new end-stage renal disease (ESRD), diagnosed with systemic lupus erythematosus (SLE) on renal biopsy and serologies including a positive ANA (>1:2560), positive anti-Sm antibodies, low titer anti-RNP antibodies, high titer anti-Ro antibodies, anti-dsDNA antibodies, lupus anticoagulant, and hypocomplementemia. She was also noted to have tender nodules on the bilateral shins. Excisional biopsy of one of the nodules showed marked fat necrosis with "ghost cells" and patchy basophilic granular debris consistent with pancreatic panniculitis. Further examination for pancreatic pathology showed an elevated lipase of 585 U/L (reference range 8-78 U/L) and amylase of 214 U/L (reference range 25-125 U/L). However, computed tomography imaging showed no evidence of pancreatitis or pancreatic tumors. This is very similar to another case recently reported in the literature. Similarities of these two cases (African-American females with lupus nephritis on dialysis) may represent a particular subset of SLE patients at increased risk for pancreatic panniculitis.

Pancreatic panniculitis in a patient with pancreatic-type acinar cell carcinoma of the liver--case report and review of literature

Background

Pancreatic panniculitis is a rare condition, which has only been described in relation with pancreatic diseases up to now. It is characterized by necrotizing subcutaneous inflammation and is thought to be triggered by adipocyte necrosis due to systemic release of pancreatic enzymes with consecutive infiltration of neutrophils. We present the first case of a patient with pancreatic panniculitis caused by pancreatic-type primary acinar cell carcinoma (ACC) of the liver and without underlying pancreatic disease.

Case presentation

A 73-year old Caucasian female patient was referred to our department with painful cutaneous nodules persisting for eight weeks and with marked lipasemia (~15000 U/l; normal range <60 U/l). Four weeks prior, several liver lesions had been detected. Empiric treatment with steroids did not show any effect. A biopsy of the skin nodules revealed “pancreatic” panniculitis, while abdominal imaging with ultrasound, computed tomography and magnetic resonance imaging detected no abnormal pancreatic findings. Ultrasound-guided biopsy of the liver lesions showed infiltrates of an ACC. The patient died soon thereafter. Autopsy failed to reveal any other primary for the ACC, so that a pancreatic-type ACC of the liver was diagnosed by exclusion.

One hundred thirty cases of pancreatic panniculitis published within the last 20 years are reviewed. ACC of the pancreas is the most common underlying neoplastic condition. Patients with associated neoplasm are significantly older, take longer to be diagnosed and have higher lipase levels than patients with underlying pancreatitis.

Extrapancreatic pancreatic-type ACC is very rare, but shows the same biological features as ACC of the pancreas. It is believed to develop from metaplastic or ectopic pancreatic tissue. Up to now, no pancreatic panniculitis in extrapancreatic ACC has been described.

Conclusion

Pancreatic panniculitis should always be included in the differential diagnosis of lipolytic panniculitic lesions. It can be regarded as a facultative paraneoplastic phenomenon.

When suspected, a thorough work-up for identification of the underlying disease is mandatory and extrapancreatic lesions (e.g. liver) should also be considered. While administration of octreotide or steroids can sometimes alleviate symptoms, immediate treatment of the associated condition is the only effective management option.

Pancreatic panniculitis in a child

Pancreatic panniculitis is an uncommon cause of panniculitis. It is associated with acute or chronic pancreatic disease. 1½ year old boy was referred for erythematous tender nodules involving both legs and associated with abdominal distention, fever, and vomiting. Dermatological examination revealed multiple erythematous tender nodules distributed over front and back of legs. Blood chemistry showed raised serum amylase (430 IU/ 1). Ultrasonography showed a pseudopancreatic cyst. Multislice CT scan was suggestive of a pseudopancreatic cyst. A skin biopsy showed typical features of pancreatic panniculitis which included lobular panniculitis with lipocyte degeneration with few Ghost cells.

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

Panniculitis can be the initial presentation of both alpha-1 antitrypsin deficiency and pancreatic disease. They can both present with abscess-like draining nodules, but may present like other forms of panniculitis with erythematous nodules. It is important to consider these in the differential diagnosis of patients presenting with panniculitis. Alpha-1 antitrypsin deficiency is a relatively common disorder mainly affecting the lungs and liver. It frequently goes undiagnosed, yet critical interventions can be made to minimize disease progression. Panniculitis associated with alpha-1 antitrypsin deficiency can be difficult to treat. Pancreatic panniculitis occurs in less than 3% of patients with underlying pancreatic disease and is often associated with arthritis. Diagnosis and treatment of the underlying pancreatic disease is imperative.

Pancreatic panniculitis in a 4-year-old child with nephrotic syndrome

Pancreatic panniculitis is an uncommon disorder with a distinctive histopathology. We report the youngest patient with pancreatic panniculitis caused by hypertriglyceridemia in association with nephrotic syndrome.

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.

Disturbances of the microcirculation in acute pancreatitis

BACKGROUND

Severe acute pancreatitis is characterized by pancreatic necrosis, resulting in local and systemic inflammation. Pancreatitis affects both the systemic and pancreatic vasculature. This review focuses on the underlying processes involved in the changes of microvascular anatomy following acute pancreatitis.

METHODS

A Medline/PubMed search (January 1966 to December 2005) with manual cross-referencing was conducted. All relevant articles investigating the pancreatic microcirculatory anatomy and the effect of pancreatitis on the microcirculation were included.

RESULTS

The pancreas is susceptible to ischaemic insult, which can exacerbate acute pancreatitis. There is also increasing evidence of pancreatic and systemic microvascular disturbances in the pathogenesis of pancreatitis, including vasoconstriction, shunting, inadequate perfusion, and increased blood viscosity and coagulation. These processes may be caused or exacerbated by ischaemia-reperfusion injury and the development of oxygen-derived free radicals.

CONCLUSION

Acute pancreatitis impairs the pancreatic and systemic microcirculation, which is a key pathological process in the development of severe necrotizing disease.

Lupus-associated pancreatitis

A number of lupus patients develop episodes of acute "idiopathic" pancreatitis, unrelated to the known causes of mechanical obstruction of the pancreatic duct or toxic-metabolic etiologies. This lupus-associated pancreatitis is rare. The estimated annual incidence was 0.4-1.1/1000 lupus patients. A literature search found detailed descriptions of this condition in 77 lupus patients. Their median age was 27, and 88% were females. Abdominal pain was the most frequent pancreatitis-related symptom (88%). In 97% the diagnosis of pancreatitis was based on laboratory evidence of elevated serum amylase or lipase. Most cases were unrelated to treatment with steroids or azathioprine. Most of the patients (84%) had active lupus at the time of pancreatitis. Mortality rate was 27%, higher than in non-SLE associated pancreatitis. Active lupus and several biochemical abnormalities, but not treatment with steroids or azathioprine, were significantly associated with increased mortality. Treatment with steroids lowered the mortality by 67% compared to non-treated patients.

Pleomorphic Basal Cell Carcinoma: Case Reports and Review

Pleomorphic basal cell carcinoma is a pathologic variant of basal cell carcinoma characterized by the presence of atypical-appearing, mononuclear or multinucleated giant cells. Including our 3 patients, a total of 52 pleomorphic basal cell carcinomas have been described in 48 individuals. The tumors usually present as a nodule on the head or neck. The nuclei of the giant tumor cells are irregularly shaped, hyperchromatic, and 2 to 10 times larger than the nuclei of the surrounding cancer cells. Atypical mitoses may be present. The pathogenesis of pleomorphic basal cell carcinoma remains to be determined; however, investigations utilizing electron microscopy, immunohistochemistry, image analysis, and flow cytometry have provided additional insight regarding the features of the giant tumor cells and the etiology of this cancer. All of these tumors are aneuploid. Although these aneuploid tumors have alarming microscopic features, their clinical course is similar to that of basal cell carcinomas without pleomorphic giant tumor cells. Therefore, appropriate therapy to ensure adequate treatment of the tumor is recommended. Our patients' pleomorphic basal cell carcinomas were successfully treated by excision using the Mohs micrographic surgical technique.

Lupus-Associated Pancreatitis

OBJECTIVES

Involvement of the pancreas in systemic lupus erythematosus is rare. The purpose of this article is to provide a detailed review of lupus-associated pancreatitis.

METHODS

We describe 3 patients with lupus-associated pancreatitis and review the English literature of the last 30 years, including the demographic, clinical, therapeutic, and prognostic aspects of this disorder.

RESULTS

There were detailed descriptions of 77 patients, 88% were females. Median age was 27 years. In 44% of the patients pancreatitis developed within 1 year of the diagnosis of lupus, and 84% had active lupus at the time of pancreatitis. Abdominal pain was the most frequent pancreatitis-related symptom (88%), followed by nausea or vomiting (67%). In 97% the diagnosis of pancreatitis was based on laboratory evidence of elevated serum amylase or lipase. Abdominal computerized tomography and ultrasonography did not show signs of pancreatic involvement in 24 and 45%, respectively. The mortality rate was 27%; active lupus and some biochemical abnormalities were significantly associated with increased mortality. Treatment with corticosteroids or azathioprine was not associated with increased mortality. On the contrary, mortality was decreased in patients who were treated with these agents after the onset of pancreatitis (20% mortality, compared with 61% among those who were not treated with steroids for their pancreatitis, P = 0.005).

CONCLUSIONS

Pancreatitis should be suspected in any SLE patient with abdominal pain. Mortality rate is related to both active lupus and some biochemical markers. In most cases, the onset of pancreatitis appears unrelated to previous treatment with steroids or azathioprine. Moreover, treatment with these medications improves prognosis.

Malignant Basomelanocytic Tumor Manifesting as Metastatic Melanoma

We report a case of an unusual basomelanocytic tumor from the scalp of a 56-year-old man. A 56-year-old white man presented with a scalp lesion that was biopsied and interpreted as a basal cell carcinoma. Fourteen months later, metastatic melanoma was discovered in a cervical lymph node and the liver. A subsequent biopsy from the area of the previously biopsied basal cell carcinoma of the scalp showed an invasive malignant melanoma. Immunohistochemical stains performed on the original scalp specimen showed biphasic immunohistochemical profile. A population of neoplastic cells was strongly positive for the melanocytic markers Melan-A, HMB-45, and tyrosinase and showed weak focal immunoreactivity for S-100. A second population of cells was strongly immunoreactive for keratin (wide-spectrum polyclonal antibody) and BerEp4. To our knowledge, this is the first description of a malignant basomelanocytic tumor complicated by metastatic melanoma.

Panniculitis and lipodystrophy

Panniculitis and lipodystrophy are rare disorders of subcutaneous tissue. Recently the incidence of lipodystrophy has been increasing secondary to its appearance in patients with HIV. In this population, the lipodystrophy appears to be a direct consequence of drug therapy. A review of the available literature regarding pathogenesis and treatment options is discussed. The diagnosis of panniculitis has been hampered by problems. The recent literature has concentrated on ways of improving pathologic diagnostic yields, and new aids in diagnosis are presented.