CASE REPORT
A 34-year-old woman with a history of acute alcoholic pancreatitis presented with complaints of epigastric pain, nausea, and vomiting. She reported alcohol use a few days prior to the onset of symptoms. Lipase level was elevated at 2,040 IU/L. Abdominal/pelvic computed tomography (CT) showed peripancreatic fat stranding and fluid consistent with acute pancreatitis as well as a few cystic structures in the head and neck of the pancreas possibly representing developing pseudocysts. Her symptoms improved slowly with conservative management, and she was discharged home on day 6.
One week later, she returned to emergency department with recurrent pain, nausea, vomiting, abdominal pain, and new erythematous tender nodules on lower extremities (Figure 1). Abdominal/pelvic CT revealed a massive pseudocyst within the left side of the abdomen, anterior to the body and tail of the pancreas, measuring 20 × 12 × 15 cm (Figure 2). Over the next 3 days, the patient reported worsening abdominal pain and increasing number of tender nodules on her lower extremities. Repeat CT showed spontaneous rupture of a pseudocyst into the peritoneum with pancreatic ascites, which was treated with surgical lavage and supportive care. She was discharged 8 days postoperatively. Three days later, she was rehospitalized for recurrent gastrointestinal symptoms. The painful skin nodules had progressed to the upper extremities (Figure 1). CT abdomen/pelvis now revealed hemorrhagic transformation of the remaining cyst and necrotic changes in the pancreatic head. After stabilization, she underwent skin biopsy, which showed dense inflammation with many neutrophils and necrosis along with ghost cells, consistent with pancreatic panniculitis (PP) (Figure 3). Her symptoms improved slowly over 2 weeks with conservative management, and she was discharged home with the subsequent resolution of her skin lesions a week later.
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Figure 1.: Erythematous tender skin nodules on the (A) legs and (B) arms bilaterally in a patient with a massive pancreatic pseudocyst after recurrent acute alcoholic pancreatitis.
Figure 2.: Computerized tomography of the abdomen and pelvis with intravenous contrast showing a massive pseudocyst within the left side of the abdomen.
Figure 3.: Cutaneous biopsy histologic sections of a patient with pancreatic panniculitis. (A) Histologic section showing an abundance of neutrophils with associated fibrinoid debris, consistent with abscess (H&E stain, 200× magnification). (B) In association with inflammation is an irregularly shaped, semi-arborizing structure composed of basophilic material encasing eosinophilic substances suggestive of ghost cells (H&E stain, 200× magnification). (C) High power magnification of the irregular structure showing eosinophilic material in a globular configuration, suggestive of ghost cells observed in saponification-type reaction associated with fat necrosis (H&E stain, 400× magnification). H&E, hematoxylin & eosin.
PP is necrosis of subcutaneous fat that is believed to be secondary to high serum levels of pancreatic enzymes.1 It is seen in 0.3%–3% of all patients with pancreatic diseases (pancreatitis or pancreatic cancer), with a male preponderance.2–4 PP in association with spontaneous rupture of a pancreatic pseudocyst has been rarely reported in the literature.5 In 40% of the cases, PP precedes abdominal symptoms of pancreatic disease, and hence may provide diagnostic clue.2 PP typically presents as painful, tender, erythematous to violaceous nodules in the lower extremities; disseminated fat necrosis may be indicative of worsening pancreatic disease.2,3 Prompt recognition of disseminating PP and appropriate management of underlying pancreatic disease may improve clinical outcomes.
DISCLOSURES
Author contributions: A. Jehangir reviewed the literature, wrote the manuscript, and is the article guarantor. A. Qureshi reviewed the literature and revised the manuscript. B. Le interpreted and provided captions for the pathology images. AA Donato reviewed the literature and revised the manuscript.
Financial disclosure: None to report.
Previous presentation: This case was presented as a poster at the 2018 ACG Annual Meeting; October 5–10, 2018; Philadelphia, Pennsylvania.
Informed consent was obtained for this case report.
REFERENCES
1. Requena L, Sánchez Yus E. Panniculitis. Part II. Mostly lobular panniculitis. J Am Acad Dermatol. 2001;45(3):325–61.
2. Rongioletti F, Caputo V. Pancreatic panniculitis. G Ital Dermatol Venereol. 2013;148(4):419–25.
3. Fernández-Sartorio C, Combalia A, Ferrando J, et al. Pancreatic panniculitis: A case series from a tertiary university hospital in Spain. Australas J Dermatol. 2018;59(4):e269–72.
4. McKee P, Calonje E, Granter S. Pathology of the Skin With Clinical Correlations, 3rd edn. Elsevier Mosby: New York, NY, 2007, pp 357–9.
5. Kobayashi H, Itoh T, Shima N, et al. Periduodenal panniculitis due to spontaneous rupture of a pancreatic pseudocyst into the duodenum. Abdom Imaging. 1995;20(2):106–8.
