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Panniculitis due to pancreatic disease

We report on a 54-year-old man who presented with painful nodules on the arms and legs that had developed four days before (Figure 1a, b). He was febrile and complained of pain in the knees. He had been admitted as in-patient to the Department of Internal Medicine because of acute pancreatitis of unknown reason ten days before. While abdominal ultrasound showed no pathological changes, magnetic resonance imaging revealed alterations of the pancreatic tissue consistent with damage due to chronic inflammation. The patient had no history of alcohol abuse, but had a previous episode of pancreatitis five years before. Other comorbidities were high blood pressure, gastroesophageal reflux disease, hypertrophy of the left ventricle and atrial fibrillation. Blood samples showed elevated lipase (7 231 U/l), amylase (1 036 U/l), and lactate dehydrogenase (828 U/l) levels while GOT, GPT and γ-GT were only slightly increased. There was no eosinophilia. To confirm the suspected diagnosis of pancreatic panniculitis a deep skin biopsy from the right thigh was obtained. The histology revealed lobular panniculitis with extensive fat necrosis, anuclear adipocytes (ghost cells), focal calcification and granular basophilic material surrounded by a dense inflammatory infiltrate of neutrophils, Clinical Letter lymphocytes and foam cells, consistent with a diagnosis of pancreatic panniculitis (Figure 2a, b). Upon conservative treatment including antibiotic therapy with meropenem the patient’s acute pancreatitis resolved. The lesions on legs and arms were treated with clobetasol propionate cream. Under continued antibiotic treatment the patient also received a short-time systemic treatment with oral prednisolone that was prescribed to target his arthralgia. Arthralgia improved and the nodules resolved within four weeks leaving only hyperpigmentation. Panniculitis is a heterogeneous group of inflammatory diseases of the subcutaneous fat tissue that may be associated with various underlying conditions [1]. Pancreatic panniculitis was first described 1883 [2] and affects 2–3 % of all patients with pancreatic disease, mostly middle-aged men [1, 3, 4]. It predominantly involves distal parts of the lower extremities, but also thighs, arms, buttocks or trunk [2, 5]. Lesions are characterized by isolated or multiple ill-defined erythematous to brownish, tender, hyperthermic plaques and nodules, which may be painful or asymptomatic [4, 5]. Nodules may fade away spontaneously leaving an atrophic hyperpigmentation. Occasionally, sterile necrotic abscesses and ulcerations may develop, secreting a viscid brown oily sterile exudate [2, 5–7]. Differential diagnoses include other forms of panniculitis such as erythema nodosum, erythema induratum, lupus panniculitis, Weber-Christian panniculitis and alpha-1 antitrypsin deficiency as well as infections, cutaneous metastases or panniculitis-like T-cell lymphoma [2, 5]. Variants of panniculitis may be differentiated by their predilection sites: the red-brown subcutaneous nodules of erythema nodosum present on the extensor surfaces of the