A memorable patient
Clinical and Experimental Dermatology
An uncommon cause of panniculitis
and G. S. Van Schalkwyk
Department of Dermatology, Derby Teaching Hospitals, London Road Community Hospital, London Road, Derby, UK
An 82-year-old man presented with a 1-year history
of tender, erythematous, subcutaneous nodules mainly
on both legs, but a few on the arms, up to 30–50 mm
in diameter (Fig. 1).
A deep incisional biopsy conﬁrmed the clinical suspi-
cion of panniculitis. Histology revealed a normal epi-
dermis with a mild perivascular inﬂammatory inﬁltrate
in the dermis, consisting of lymphocytes and eosino-
phils. In the underlying subcutaneous tissue, there
was extensive enzymatic fat necrosis and a mixed
inﬂammatory inﬁltrate with histiocytes. Multiple anu-
cleate ghost cells were seen, composed of amorphous
granular debris often with a rim of eosinophilia. This
was in keeping with pancreatic panniculitis (Fig. 2).
The patient’s full blood count, liver function tests, phos-
phate and adjusted calcium were within normal limits. His
lipase level was signiﬁcantlyraisedat7674IU/L(normal
range with a raised erythrocyte sedimentation rate of
67 mm/h (0–20 mm/h), so pancreatitis was suspected,
but the amylase level was within normal limits at 45 IU/L.
On further questioning, the patient reported he had been
feeling generally unwell with diarrhoea and occasional
abdominal pain for the past 8 months.
Computed tomography was performed and the scan
reviewed by the hepatobiliary multidisciplinary team
meeting. A lesion at the tail of the pancreas was
found, with a small lesion in the liver and nodes in
the lung, felt to be consistent with a pancreatic
tumour with metastases.
Endoscopic ultrasonography and biopsy were con-
sidered to get a histological diagnosis. This was dis-
cussed with the patient and his wife, but because of
his age and comorbidities, he preferred not to have
any further investigations or treatment. Sadly, he died
5 months after his initial dermatology appointment.
Panniculitis can be a diagnostically challenging pre-
sentation with a long list of potential differentials.
There is a dynamic pathological process with different
stages of evolution. Inﬂammation in the subcutaneous
tissue is distant from the visible surface, and subtypes
have a complex and often contradictory classiﬁcation.
A large and deep incisional biopsy is mandatory to
obtain a specimen of tissue that is adequate to allow
the histological patterns to be assessed.
Correspondence: Dr Tom King, Dermatology Department, Derby Teaching
Hospitals, London Road Community Hospital, London Road, Derby, DE1
Conﬂict of interest: the authors declare that they have no conﬂicts of
Accepted for publication 13 April 2017
Tender erythematous subcutaneous nodules on the leg.
ª 2017 British Association of Dermatologists Clinical and Experimental Dermatology (2018) 43, pp351–353