Necrotizing Panniculitis, a Skin Condition Associated with Acinar Cell Carcinoma of the Pancreas

Abstract

Purpose: Pancreatic panniculitis is a rare cutaneous eruption due to leak of pancreatic lipase into the bloodstream with subsequent focal necrosis of adipose that is sometimes associated with panceatic disease. We describe an unusual patient with this skin condition who presented to our hospital for evaluation of skin lesions of uncertain etiology with associated diarrhea and arthralgias. Methods: A sixty-one year old man complained of a four month history of subjective fever, pain in his ankles, knees and wrists, and a painful rash that spread from his legs to the abdomen and arms. The cutaneous eruption comprised inflamed-looking papules and pustules on an erythematous base that drained dark, purulent, foul-smelling fluid. The patient also made note of diarrhea which had been progressive over four months. Lipase levels, drawn to investigate the patient's chronic diarrhea, were elevated to three hundred times the reference limit. Amylase, ALT, AST and bilirubin were mildly elevated. A CT scan of the abdomen revealed a mass in the tail of the pancreas with nodules in both the liver and the base of the left lung. A CT-guided needle biopsy of one of the liver nodules revealed histology consistent with Acinar Cell Carcinoma of the Pancreas. The cancer was stage IV at the time of presentation. The skin eruption was diagnosed to be nodular subcutaneous fat necrosis, also known as pancreatic panniculitis. The patient was offered palliative treatment. Results: Pancreatic panniculitis is rare, occurring in 2–3% of all patients with pancreatic disorders. Occasionally, it is associated with cancers of the pancreas, especially with acinar cell carcinoma which itself represents only one to two percent of pancreatic malignancies. As of 1995 fewer than 40 described cases of acinar cell carcinoma of the pancreas have presented with poly-arthralgia and disseminated fat necrosis, both seen in our patient prior to the discovery of his pancreatic malignancy. Conclusions: In clinical practice the skin manifestations of internal malignancies vary in their presentation. They may challenge primary care physicians and dermatologists when patients present without associated findings for malignancy. Panniculitis should be kept in mind in the differential diagnosis of inflamed appearing nodules and pustules with an erythematous base, such as the ones observed in our patient, particularly when they are progressive and unrelenting. They may be the clue to the discovery of a potentially serious disease.