Panniculitis is a rare skin entity that is characterized by subcutaneous fat necrosis. It affects around 2–3% of patients with pancreatic disease. Panniculitis is most commonly present in patients with acute or chronic pancreatitis. However, it is also associated with pancreatic acinar cell carcinoma. Most of the patients present with erythematous, painful cutaneous nodules on the lower extremities as the first symptom of the underlying pancreatic disease.
The exact aetiology of pancreatic panniculitis is vague. However, the release of pancreatic enzymes such as lipase, amylase, and trypsin into circulation is contributing to the pathogenesis of pancreatic panniculitis.
In this case, a 77-year-old woman visited the dermatology ward complaining of several persistent and painful cutaneous nodules on the left lower extremity. The nodules were itchy and warm. The nodules with time had progressed to both legs. The patient’s past medical history was non-significant. However, she was a past smoker and an alcoholic. She was habitual of drinking 14 units of alcohol per week. The patient had no history of weight loss or abdominal pain. Her family history was positive for lung cancer because both her parents had died from this disease. Whereas, she had no further family history of gastrointestinal or pancreatic disorders. Moreover, she also had a drug history of using the following medications: allopurinol, omeprazole, metoprolol, indapamide, and pravastatin.
The doctors performed a physical examination which revealed the three erythematous nodules that were visible on both legs. Their size ranged from 1 to 4 cm. One of the nodules was slightly red whereas the other two were dark red to purple-blue. On further clinical examination, the doctors revealed that the nodules were painful on palpation. The doctors concluded that these cutaneous lesions suggest the diagnosis of panniculitis.
The doctors carried out some investigations which included a skin biopsy. The skin biopsy revealed typical histological features of pancreatic lobular panniculitis. The specimen taken from a nodule showed a neutrophilic infiltration and focal necrosis of adipocytes with anucleated cells called the “ghost cells”. Also, the doctors performed a blood test which showed an elevated pancreatic enzyme. The lipase serum level was greater than 3000 U/L.A computed tomography (CT) scan ruled out the signs of metastases and showed a mass present between the stomach and the left side of the pancreas. The mass had a diameter of 7.4 cm. Endoscopic ultrasound-guided fine-needle biopsy made a final histopathological diagnosis of the acinar cell carcinoma of the pancreas.
The pancreaticobiliary multidisciplinary team advised the patient about the distal pancreatectomy including splenectomy. Her vitals including pulse, temperature, and blood pressure were all normal on admission to the hospital. The laparoscopic surgery lasted 7 hours. Additionally, local resection of the stomach was also performed due to the presence of a tumour. The resected specimen confirmed the diagnosis of acinar cell carcinoma. However, the surgical margins were free of tumours and there were no metastases found in the 12 examined lymph nodes.
The patient fully recovered on the fourth postoperative day. She had no complications during the stay. However, the patient received paracetamol, oxycodone, phenethicillin, and magnesium hydroxide after the splenectomy. The liver function test, renal test, in addition to other tests were all normal. Moreover, the cutaneous nodules on both legs faded away within 1-2 days after the surgery.
Postoperatively, the patient was advised to adjuvant chemotherapy. However, the patient rejected this because the benefit of adjuvant chemotherapy for this rare pancreatic acinar cell carcinoma was not well established due to the limitation of the data. On the follow-up, the patient had no long-term complications in his fourth and sixth postoperative month and she had recovered well.
Recurrence of the pancreatic cell carcinoma
One year later, after the surgery, the patient came to the emergency room with the same symptoms that she experienced preoperatively.
The doctors immediately performed the CT scan. The scan showed both local and distal metastases. The doctors further confirmed it through a biopsy. The doctors started chemotherapy. Furthermore, the patient was given two cycles of palliative folinic acid–fluorouracil–irinotecan–oxaliplatin (FOLFIRINOX) but stopped afterwards because of no progression. However, the patient did not respond to the treatment and died after two months.
“The cutaneous nodules lead to a diagnosis of pancreatic cell carcinoma“
This article emphasizes the importance of cutaneous nodules as the major symptom of pancreatic panniculitis. The underlying cause can be any pancreatic disease whether benign or malignant. However, any nonspecific nodules located in the lower leg should undergo the investigation of a skin biopsy to reach a final diagnosis. Moreover, doctors should perform a detailed investigation to differentiate between benign and malignant causes.
Therefore, It is always necessary to include a multidisciplinary team in such rare diseases.
Reference: Journal of Medical Case Reports