University of Virginia Digestive Health Center Charlottesville, VA, United States
Anne Tuskey, MD, Mark J. Radlinski, MD University of Virginia Digestive Health Center, Charlottesville, VA
Introduction: We report the case of a 65-year-old woman who was hospitalized for acute alcoholic pancreatitis and sub-acute development of bilateral, painful, and weeping lower extremity sores. The gastroenterology and dermatology services were both consulted for further management.
Case Description/Methods: Our patient is a 65-year-old woman with alcohol use disorder who was hospitalized for acute pancreatitis based on cross sectional imaging and serology. She had a history recurrent acute pancreatitis, previously believed to be secondary to non-IgG 4 mediated autoimmune disease (unresponsive to steroid therapy), now thought likely to be alcohol induced. Upon presentation to the hospital, she reported bilateral, lower extremity sores that had been intermittently present, waxing and waning in severity, over the previous four months. She noted that these sores were both painful and would intermittently drain serosanguinous fluid. Dermatology was consulted and a punch biopsy was performed. The punch biopsy demonstrated dermal fibrosis and dense neutrophilic inflammation, extending through the dermis and into the subcutis. There was evidence of necrotic adipocytes, otherwise known as “ghost adipocytes”. Additional findings included deposition of basophilic material consistent with saponification. The collection of aforementioned histopathologic features was felt to represent a diagnosis of pancreatic panniculitis. Bacterial, fungal, and atypical mycobacteria stains were obtained to rule out infection and were all negative.
Discussion: Pancreatic panniculitis is a rare complication of pancreatitis. The pathophysiology involves necrosis of the fat in the panniculus. This is thought to occur in the setting of pancreatic inflammation. While the mechanism of action is not well understood, this dermatologic finding is associated with thickened, painful, and firm nodules of the lower limbs. The constellation of aforementioned histology findings is classic for pancreatic panniculitis but infectious processes should be ruled out as was done in our patient. Pancreatic panniculitis is notoriously difficult to treat with topical therapy or intralesional injections. Unlike other causes of panniculitis, the treatment of pancreatic panniculitis is to address the cause of the underlying pancreatic pathology. Additionally, compression stockings (if the patient does not have arterial insufficiency) can sometimes facilitate the healing process. (Informed consent was obtained from this patient to publish this case).
Figure: A: Photograph of Rash on Presentation B. Dermal Fibrosis and Dense Neutrophilic Inflammation C. Necrotic Adipocytes, Otherwise Known as “Ghost Adipocytes”
Disclosures: Anne Tuskey indicated no relevant financial relationships. Mark Radlinski indicated no relevant financial relationships.
Anne Tuskey, MD, Mark J. Radlinski, MD. P1096 - A Peculiar Rash: A Case of Pancreatitis Panniculitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
