Erythematous Swelling Research Articles

Extensive Fournier’s Gangrene Due to Delayed Management of Perianal Abscess in Uncontrolled Diabetes: A Case Report

Abstract Fournier’s gangrene is a rapidly spreading gangrene predominantly affecting the genital and perianal region. It has the highest mortality and is more common in immunocompromised and diabetic patients. Poorly controlled diabetes is one of the common risk factors for Fournier’s gangrene. Delayed diagnosis and treatment increase mortality by nearly 100%. In our case, the patient was initially managed for a perianal abscess and later progressed to Fournier’s gangrene. A 48-year-old male diabetic presented with erythematous swelling in the right-side scrotal region for one-week duration. He had a recent perianal abscess and underwent incision and drainage at another hospital He also reported fever with chills and rigors for the past two days. The patient is now in a state of septic shock. He has a history of irregular medication for type 2 diabetes mellitus. Clinical examination confirmed Fournier’s gangrene resulting from a perianal abscess in the context of uncontrolled diabetes. The patient underwent an emergency wound debridement under spinal anesthesia. Extensive wound debridement was performed on the right hemiscrotum. Necrotic tissue was debrided on the right perianal region. The patient was initiated on empirical antibiotics, receiving a calculated dose of cefoperazone with sulbactam and metronidazole. Additionally, the patient underwent sitz baths and received regular wound dressing. Following wound debridement and glycemic control with insulin, the patient showed signs of improvement. Four weeks post-debridement, the patient underwent split-skin grafting for the raw area on the scrotum, while the fistula site was allowed to heal by secondary intention. The cornerstone in managing perianal abscess with Fournier’s gangrene in diabetic patients is extensive wound debridement, antibiotic coverage, and proper management of diabetes. Early diagnosis and prompt surgery of perianal abscess can reduce the risk of developing Fournier’s gangrene in diabetic patients. Post-surgical raw areas can be effectively managed with split-skin grafts.

Borrelial lymphocytoma of the areola in a 9-year-old boy: a case report

Purpose: This study presents a rare skin manifestation of Lyme borreliosis, specifically affecting the areola in a child in the absence of a history of a tick bite or erythema migrans. 
 Case report: A 9-year-old boy presented with symptomless erythematous swelling of the breast areola for one month. Initial treatment for gynecomastia and then mastitis proved ineffective. A biopsy was performed, with histological findings revealing lymphocytoma, likely stemming from an insect bite. Serology for Borrelia burgdorferi was positive. Following a two-week course of oral amoxicillin, the lesion completely resolved. 
 Conclusion: The consideration of Lyme disease should be a component of the differential diagnosis of skin lesions localised in typical areas, particularly in patients living in endemic regions.

Medication-Related Osteonecrosis of the Jaw: A Cross-Sectional Study on the Prevalence of Cutaneous Manifestations and the Primary Care Physician's Role in its Early Diagnosis

BackgroundMedication-related osteonecrosis of the jaw (MRONJ) is a side effect in patients undergoing treatment with bone-modifying agents (BMA) for cancer or osteoporosis. Although most cases are treated by oral medicine specialists, some cases may present extraorally as a fistula in the skin or erythematous swelling localized to the jaw area, causing these patients to consult a primary care physician. This study examined the prevalence and clinical characteristics of extraoral manifestations of MRONJ in a large cohort to raise awareness among primary care physicians of this entity, enabling prompt diagnosis and treatment. MethodsMedical records were retrieved of patients diagnosed with MRONJ between 2003 and June 2020 in the Oral Medicine Unit of The Sheba Medical Center, Israel. Data relating to demographics, medical background, type of BMA, and clinical presentation were collected. ResultsIn total, 515 patients (378 women [73%] and 137 men [27%]; mean age: 65 years, range: 32-94 years) met the inclusion criteria, among whom 84 (16.5%) presented with extraoral manifestations of MRONJ. Of these 84 patients, 21 (24.7%) presented with extraoral fistulas. Extraoral manifestations were strongly correlated with MRONJ of the mandible (n = 67; P = .0006). ConclusionsMRONJ is a significant side effect of BMA therapy. Although MRONJ mostly presents intraorally, some patients may initially present with extraoral manifestations of erythematous swelling or fistulas localized to the jaw area. Primary care physicians should consider MRONJ as a differential diagnosis in such patients.

Lemierre's syndrome: an evolving disease

Lemierre’s syndrome is characterized by thrombophlebitis of the internal jugular vein with resulting systemic septic emboli. Most cases occur following an oropharyngeal infection and have been historically caused by the bacterial pathogen Fusobacterium necrophorum. However, infection from other pathogens is becoming more common in recent years. Our case is special in the sense that Lemierre’s syndrome was caused by staphylococcus aureus after influenza infection. A 23-month-old male presented with complaints of left neck swelling and recurrent fever for one week, following influenza A infection. The child was ill-appearing with fever, tachycardia, tachypnea, and erythematous swelling on the left cheek. Laboratory results revealed elevated inflammatory markers. Computed tomography (CT) scan of the neck showed loculated fluid collection suggesting an intra parotid abscess with poor visualization of the internal jugular vein (IJV). Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Due to high clinical suspicion of Lemierre’s syndrome, a doppler ultrasound was obtained which showed a left IJV thrombus. CT scan of the chest after the clinical suspicion showed multiple bilateral pulmonary nodules suggesting septic emboli. He was treated with antibiotics and a six-week course of the anticoagulant with a resolution of his thrombus. Though historically, Lemierre’s disease is caused by Fusobacterium necrophorum, other causative organisms such as methicillin-sensitive Staphylococcus aureus are increasingly being recognized. Lemierre’s disease can present as a complication of influenza. A high index of clinical suspicion based on the location of the abscess helped us delineate diagnostic tests and treatment.

VEXAS syndrome mimicking lupus-like disease.

Dear Editor, We report on an 81-year-old male Caucasian patient, who initially presented with oral ulcerations and disseminated erythematous papules on the upper back, chest, arms and legs with histopathological evidence of lymphocytic infiltration and small vessel vasculitis matching subacute lupus erythematous (Fig. 1A and B). His skin manifestations improved with topical CS and HCQ at standard dosages. However, a complete remission of the lesions could not be achieved. Therefore, repeated skin biopsies were performed, showing features of subacute eczema or Sweet Syndrome. Fourteen months later, the patient developed recurrent episodes of oral ulcerations, painful auricular and nasal erythematous swelling and arthritis in hands and feet (Fig. 1C and D). A hand MRI showed a moderate to severe wrist joint synovitis. Another 6 months later, he presented with clinical symptoms and laboratory findings of anaemia with increased, corpuscular volume (102.9 fl; normal range 81–98 fl), leukopoenia, lymphopenia, thrombocytopenia, increased levels of CRP, serum amyloid A and IL-6 as well as anti-mutated citrullinated vimentin (MCV) antibodies (Fig. 1G). Treatment with MTX was started at 15 mg/week and was well tolerated, leading to improvement of skin and joint symptoms. The patient experienced one episode of epilepsy with generalized convulsions. Cerebral MRI scan showed unspecific cerebral microangiopathy but no specific lesion. To rule out further foci of inflammation, an 18-fluorodeoxyglucose (18FDG)-PET/CT was performed, showing an enhanced FDG uptake typical for bone marrow activation (Fig. 1E and F), in accordance with a previous description [1]. Over the last 6 months, his skin and joints were well controlled by MTX. However, haematological and inflammatory parameters did not improve. As the patient fulfilled the major diagnostic traits of VEXAS [2], including male sex, increased corpuscular volume >100 fl and low platelets G/l, genetic testing was done. This patient was identified to carry the pathogenic variant c.121A>C, p. (Met41Leu) in exon 2 of UBA1 (NM_003334) (ACMG class 5) in mosaic state (68% of 93 reads), confirming the diagnosis of VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome.

Neonatal supporative parotitis - A case report

A 9-day old male neonate was admitted for fever. He was born at term with normal antenatal records and a smooth transition from in utero to ex utero. He was febrile and had a left-sided pre auricular hot, tender, erythematous swelling and oral purulent discharge from Stensen’s duct. The septic profile was suggestive of sepsis. Ultrasonography revealed parotid gland enlargement with pus collection. Empirical antibiotics started, and parotid swelling pus drained. Culture of Pus from parotid swelling and Stensen’s duct yielded growth of Staphylococcus Aureus. According to the sensitivity report, antibiotics continued for ten days, and the patient was discharged after complete resolution of signs and symptoms.

Ganglion of the Sternoclavicular Joint: First Case Report from Kashmir Valley

Ganglion cyst is a common swelling observed near joints of hands and feet, usually occurring in adult population. Ganglia are rare in the pediatric population. Additionally, sternoclavicular joint ganglia are also exceedingly rare. Diagnosis is usually based on clinical examination, radiological investigations, or fine-needle aspiration cytology (FNAC). We hereby report a case of an 8-year-old girl who presented with a non tender, non erythematous swelling over the right sternoclavicular joint for 2 months. FNAC of the lesion was done and diagnosis of ganglion was made. The swelling disappeared completely on aspiration. The aspiration acted both as diagnostic and therapeutic modality. The patient is under follow-up for the chance of recurrence. The case illustrates the importance of keeping ganglion within the differential diagnosis for palpable subcutaneous masses, even in young children, especially when they are seen to connect to the joint. To the best of our knowledge this is the first time to report such a case from Kashmir valley. Keywords: Ganglion cyst, sternoclavicular joint, pediatric age.

Parona space collection: A serious complication of hand infections

A 61-year-old man presented with erythematous and painful swelling of his left hand, wrist, and distal forearm for five days. He denied any penetrating injury and had no known inflammatory arthropathy or thrombophilia. There was no fluctuance or neurovascular compromise. Investigations revealed elevated leucocyte counts (14.11 × 109/L) and C-reactive protein (228 mg/L).

SQuiz your knowledge! Erythematous swelling with telangiectasia on the trunk

sQuiz your knowledge! Erythematous swelling with telangiectasia on the trunk

Plasma cell leukaemia with plasmablastic morphology and extensive extramedullary plasmacytomas

A middle-aged man presented to the acute medical unit for progressive left facial swelling with a gingival mass and right eye visual loss with erythematous ocular swelling. Subsequently he developed upper gastrointestinal tract bleeding and passed melaena, requiring blood transfusion for resuscitation. Initial blood tests found leucocytosis with circulating plasmablasts, anaemia, acute kidney injury with elevated creatinine and hypercalcaemia. Further workups by immunofixation and flow cytometry revealed IgG-lambda paraprotein and a clonal plasma cell population with lambda light chain restriction in peripheral blood.

Erizipel nakon ujeda mačke izazvan bakterijom "Pasteurella multocida" - prikaz slučaja

Introduction: Erysipelas is a characteristic form of acute superficial streptococcal cellulitis, usually treated in outpatient service, primarily with penicillin, or erythromycin, in cases where the patient is allergic to penicillin. We are reporting the case of a patient who was preventively treated with erythromycin, after a cat bite, but during treatment developed erysipelas, which, after a swab sample from the wound was analyzed, proved to be caused by Pasteurella multocida, resistant to erythromycin. Case report: A 53-year-old woman came to the outpatient clinic with clinical signs of erysipelas cruris. Seven days before, she had been bitten by her own cat. The wound was surgically treated, and erythromycin, 500 mg qid, was prescribed as prophylaxis of wound infection. There were no signs of infection. On the 5th day following the bite, the patient was running a very high fever (39.2°C), but she was without other symptoms, thus the fever was considered to be a symptom of the flu. On the following day, prominent erythematous swelling appeared around the site of the wound, with localized lymphangitis and regional lymphadenitis, and discharge from the wound. The diagnosis of erysipelas was made. The peripheral blood test results were as follows: WBC = 13.9 x 109 /l; NE = 82%, CRP = 43 IU. A swab sample was collected from the wound and the patient was started on penicillin. On the 7th day of penicillin administration, there were no signs of inflammation, while the blood test results were as follows: WBC = 5.1 x 109 /l; NE = 52%; CRP = 24 IU. Pasteurella multocida, resistant to erythromycin but sensitive to penicillin was isolated from the swab sample. Conclusion: Erysipelas, although an easily recognized clinical entity, can be caused by other microorganisms, besides streptococcus. It is very important to consider this in order to make an accurate diagnosis and prescribe the appropriate therapy.

A Rare Case of Pott's Puffy Tumor in an Elderly Man with a Background of Schizophrenia

Pott's puffy tumor (PPT) was first described by Sir Percival Pott in 1768. It is a life-threating complication of infectious sinusitis, which presents as a forehead swelling due to osteomyelitis of the frontal bone with an associated subperiosteal abscess (Hasan et al, 2019). It is not a true neoplasm; the name "tumor" refers to the swelling that occurs on the forehead as a result of the spread of infection. It is extremely rare in the post-antibiotic era and, when it does occur, tends to affect children and adolescents as the frontal sinus completes its development in preadolescents (Karaman et al, 2008). Very few cases of PPT have been documented in elderly individuals. The authors report the case of Pott's puffy tumor in a 71-year-old man with a background of chronic sinus disease, paranoid schizophrenia, and drug-induced Parkinsonism.An elderly man with a 12-day history of a worsening forehead abscess presented to the emergency department after being referred by his GP following 6 days of unsuccessful antibiotic therapy. On examination, a large, erythematous swelling was noted on his central forehead, measuring 15cm in diameter (Figure 1). The abscess was tender on palpation and fluctuant. There were no visual changes, exophthalmos, enophthalmos, or involvement of the periorbital area. The patient had a normal cranial nerve examination, except for slightly decreased sensation in the central forehead. His vital signs demonstrated tachycardia and, interestingly, he did not have a fever.The patient had a background of paranoid schizophrenia and was taking monthly injections of the typical antipsychotic flupentixol, as well as the anticholinergic procyclidine, for the drug-induced Parkinsonism. The patient lived in sheltered accommodation, smoked 10 cigarettes per day, and consumed cannabis. Recently, to note, the patient had a 2-month stay in a nearby mental health hospital.The patient was admitted, and the abscess was drained and irrigated with saline. Overnight, the abscess re-collected, and bloody nasal discharge was reported. This was re-drained the following morning, and examination after drainage suggested a possible involvement into the frontal sinus. The patient was listed for a CT scan, which demonstrated subcutaneous collection and acute frontal sinusitis complicated by erosion of the anterior wall of the frontal sinus in keeping with osteomyelitis (Figure 2). The CT scan also showed osteitis of the right frontal sinus and bilateral maxillary and sphenoid sinus walls consistent with chronic sinus disease. There was no evidence on CT of intracranial or orbital involvement.The patient was diagnosed with Pott's puffy tumor and referred to otolaryngology colleagues. The patient was commenced on IV piperacillin/tazobactam (tazocin) 4.5g tds and vancomycin 1g tds and listed for Functional Endoscopic Sinus Surgery (FESS).This case highlights the need for early recognition and prevention of benign infections that may subsequently become sinister or fatal. If not identified and managed swiftly, Pott's puffy tumor has a life-threatening sequela due to involvement into the frontal lobes of the brain. Hence, it is importance to have a high clinical suspicion for PPT in the face of medical and psychosocial risk factors. The authors emphasize the importance of a multidisciplinary team approach to managing patients with PPT, with valuable input from otolaryngology, neurosurgery, microbiology, and histopathology enhancing patient care.

Diffuse painful erythema on right thigh

A 37-year-old otherwise healthy woman presented with a 1-month history of a diffuse, painful, and erythematous swelling on her right thigh (Fig 1), along with high fever (up to 41°C) arthralgia, headache, and night sweats. She was initially treated with multiple antibiotics for infection, but the treatment failed. Routine laboratory tests showed a leukocyte count of 2.40 × 109/L (reference range: 4.00-10.00 × 109/L), lactate dehydrogenase 2213 U/L (reference range: 114-240 U/L), alanine aminotransferase 260 U/L (reference range: 1-40 U/L), and aspartate aminotransferase 626 U/L (reference range: 1-37 U/L).

Influence of the microbial factor in acute pericoronitis occurrence

Pericoronitis is an inflammatory disease that occurs after the eruption of the lower wisdom teeth and affects the surrounding tissues, with a complex microbial and traumatic etiology, manifested by an erythematous swelling and gum hyperemia in the retromolar area. The main goal was to determine the etiological spectrum of the microorganisms involved in acute pericoronitis and to evaluate the antibiotics, antiinflammatory drugs effect on pericoronitis treatment. The study included 30 patients (18 male, 12 female), aged between 18-45 years (27,8±8,2 years) with acute pericoronitis of the lower wisdom tooth. The study determined the severity of infection related to subjective and objective clinical symptoms (pain, swelling, congestion), the incidence of various streptococci; antibiotics resistance analysis was performed for in order to determine the sensibility and the rate between monomicrobial and polymicrobial cultures. 14 references, 4 figures.

Deep neck infections with mediastinum abscess and respiratory failure in a pediatric patient

Abstract Rationale: Deep neck infections are infections of the potential fascial planes and spaces of the head and neck. They can be life-threatening due to complications of upper airway compression or obstruction, sepsis or septic shock or acute respiratory syndrome. The most common pathogens are Streptococcus viridans and Staphylococcus aureus. Patient concerns: A one-year one-month-old girl was admitted to our pediatric emergency department due to fever, rhinorrhea, and erythematous swelling in the right preauricular area for 3 days. A day later, she had dyspnea, dysphagia, decreased activity, and the swelling extended to the right neck area. Diagnosis: The initial soft neck tissue radiograph showed prevertebral soft tissue thickening, and neck sonography revealed hypoechoic nodes, which were highly suggestive of a deep neck infection. Subsequent computed tomography of the neck and chest showed an abscess of the right deep neck spaces over the parapharyngeal, carotid, parotid, and submandibular areas with intrathoracic extension, as well as an abscess over the anterior mediastinum and bilateral empyema. Interventions: Drainage from deep neck incisions and thoracoscopic decortication of the right-side pleura were performed. Outcomes: After appropriate surgical interventions, critical care with antibiotics and ventilator support, the patient's condition stabilized and was discharged home. Lessons: Complications of deep neck infections are potentially fatal, especially in children. Clinicians should be aware of such infections in children and should not underestimate their potential severity. Children with deep neck infections should be more closely monitored throughout their hospitalization.

Juvenile Dermatomyositis Presenting with Erythematous Swelling of the Upper Eyelid

Juvenile Dermatomyositis Presenting with Erythematous Swelling of the Upper Eyelid

Acute Calcific Tendinitis of the Forefoot in Young Women- A Presentation of Two Cases

Introduction: Calcific tendinitis is an uncommon presentation in the forefoot with relatively few cases reported in the medical literature. It is commonly overlooked and should form part of a differential diagnosis when assessing patients presenting with acute pain of the forefoot localised to a single joint or tendon. We present two cases of young women involved in amateur running and martial arts respectively who presented with acute pain of their forefoot. Case Description: These 2 cases describe a 44 year old amateur female runner and 23 year old female martial arts athlete who presented with acute onset of pain affecting the dorsal aspect of their great toe interphalangeal joint and base of 1st metatarsal respectively. Both patients had tender erythematous swellings at the site of pain and difficulty weightbearing. Plain radiography revealed areas of calcification at the respective sites which was confirmed with ultrasound. Both patients underwent US guided corticosteroid injections with significant symptom improvement within 48 hours of injections and rapid return to sport. Discussion: These two cases demonstrate an atypical presentation of acute calcific tendinitis affecting the forefoot and add two more cases to the reported literature. Combining the characteristic clinical presentation of acute pain affecting a tendon or joint with a tender erythematous swelling on examination with the typical radiographic features of calcification can promptly diagnose this often misdiagnosed condition and avoid unnecessary investigations. Conservative treatment and intralesional injection with corticosteroids can lead to rapid resolution and favourable patient outcomes.

Oral myeloid sarcoma as an uncommon manifestation of acute myeloid leukemia: A case series and review of the literature

Background and OverviewOral myeloid sarcoma (MS) is an extramedullary tumor that can occur in the setting of acute myeloid leukemia, either as the first sign of an underlying disease or later in the course of disease. The authors’ aim was to present the clinical features of oral MS and review the literature. Case DescriptionCase 1 was an 82-year-old woman with an asymptomatic erythematous swelling on the maxillary gingiva and no history of hematologic malignancy. Case 2, a 65-year-old man, and case 3, a 58-year-old woman, each had a history of acute myeloid leukemia and a painful ulcer on the palatal mucosa and an asymptomatic ulcer on the lower lip mucosa, respectively. Case 1 was treated with focal radiation then chemotherapy and achieved complete remission initially, but died of relapse 2 years after diagnosis. Case 2 received radiotherapy and immunotherapy and had a complete response. Case 3 received chemotherapy and achieved remission initially, but relapsed and is undergoing investigational targeted therapies. Conclusions and Practical ImplicationsOral MS can manifest as gingival or mucosal swelling or ulceration and can indicate onset or relapse of associated hematologic malignancies, which often have a poor prognosis. Because patients with oral findings are likely to seek treatment from their dentists first, oral clinicians should maintain a broad differential diagnosis list when evaluating oral lesions, especially if treatment prescribed for a more common diagnosis fails to resolve the lesion.

Unisystem Langerhans cell histiocytosis in maxillofacial region in pediatrics: comprehensive and systematic review.

The study aimed to identify, enlist, and analyze cases of unisystem LCH in the maxillofacial pediatric population to understand the clinical presentation and encourage the consideration of this rare disease in the differential diagnosis. Langerhans cell histiocytosis (LCH) is an aggressive benign condition affecting mainly the pediatric population. It can be easily masked as periodontal disease in the maxillofacial region. Early diagnosis and a systemic evaluation are of utmost importance. We are presenting a complete review of literature in the pediatric population according to PRISMA guidelines for clinicopathologic, histopathological, immunohistochemistry, and treatment for unisystem LCH. The risk of bias assessment across studies was done using a Case series appraisal checklist by Guo et al. 53 RESULTS: Forty-nine articles (152 cases) were selected which met our inclusion and exclusion criteria to be included in our review. Most of the patients fall in 6-12 years of age with the involvement of the mandibular body region in 40.79% cases. This disease mainly presents as erythematous gingiva, pain, swelling, and mobile teeth. Management can range from minimal intervention to chemotherapy and surgery. Although this is a rare condition, it should be considered especially in the pediatric population with periodontitis type lesions and floating teeth and comprehensive management should be followed. Early diagnosis of the disease is very important.

O21 A rare case of anti-TNF induced panniculitis

Case report - IntroductionPanniculitides comprise a heterogeneous group of inflammatory diseases involving the subcutaneous fat. They remain the most challenging areas for clinicians. Skin biopsy is commonly needed to confirm diagnosis. Because there are many underlying aetiologies for panniculitis, detailed history and thorough investigations are needed. We present a case of A 20-year male who was admitted with painful lumps treated initially as cellulitis/abscess but turned to be neutrophilic panniculitis on skin biopsy. Extensive workup failed to reveal underlying aetiology. Eventually Imradli (AntiTNF) was thought to be the culprit and therefore was kept on hold with no recurrence of panniculitis.Case report - Case descriptionA 20-year-old, Asian Malawian. Moved to the UK at the age of 6. He was diagnosed with Ankylosing spondylitis in November 2016. Initially received Naproxen followed by (Humira) with good clinical response. He was switched to biosimilar Imradli in Nov 2019. He was admitted with 2–3 weeks history of progressive right hip and buttock pain, 1 week of very tender erythematous swelling of the right buttock but without fever or weight loss. He reported mild weakness of lower limbs. Physical examination revealed 5x 8 cm swelling on Right buttock, Rest of examination was unremarkable. He was reviewed by neurology team who arranged MRI spine and brain, EMG and lumbar puncture which all came back as unremarkable excluding the possibilities of myelitis and myositis. Initially thought to be abscess/cellulitis but absence of fever/inflammatory response, abnormal CT finding and no response to antibiotics made it less likely. While the Right buttock erythema/swelling started to resolve, he developed two new migratory erythematous lesions appearing around the left buttock and lower lumbar spine. Working diagnosis of panniculitis was made which was confirmed on biopsy. Due to lack of response to NSAIDs, colchicine or oral steroids, a 3rd biopsy of the freshest lesion was performed to exclude deep-seated infection.Investigations –FBC, U&ES, LFT, CRP, CK, ACE - all were unremarkableASO titre <200, serology for Borrelia and TPHA negative.Viral, parasitic, and Autoimmune screen were unremarkable.CXR clear, MRI/CT: extensive subcutaneous inflammatory changes in the right buttock with sacral oedema.PET-CT – showed resolving inflammatory changes in the right flank, FDG intake in C6 and SI joints presumed secondary to ankylosing spondylitis and sacroiliitis.The underlying cause of panniculitis remains uncertain. Anti TNF was kept on hold and the patient was followed up with no evidence of recurrence of panniculitisCase report - DiscussionPanniculitis (inflammation of subcutaneous fat) is a relatively uncommon condition. It has various aetiologies including infection, trauma, inflammation, and malignancy. Skin biopsy can give valuable information including microbiological studies if infectious panniculitis was suspected. However, clinical correlation and careful consideration of the differential diagnosis is needed in many cases.The diagnosis can be quite challenging as in this case where all investigations and skin biopsy could not point towards the underlying aetiology. Although anti-TNF inhibitors are commonly used in treating a wide range of autoimmune conditions. But their use can lead to the development of secondary autoimmune diseases, such as cutaneous vasculitis, lupus-like syndrome, and interstitial lung disease, paradoxically induced by anti-TNF-α agents. Llamas-Velasco and Requena, reported the first case of panniculitis induced by etanercept injection in a 62-year-old woman with severe psoriasis who developed an erythematous, slightly painful nodule on the skin of the anterior abdominal wall.Adalimumab induced lupus panniculitis was reported in a Rhu-lupus patient. Although the lesions stopped progressing after cessation of adalimumab, they remained unchanged for two more years. The mechanism for adalimumab-induced CLE is uncertain.Although there is not enough data about autoimmunity with biosimilars, we think secondary autoimmune conditions could similarly be induced by biosimilar as illustrated in this case. Anti-TNF induced cutaneous panniculitis is considered most likely although uncertain. If anti-TNF drug-induced, this should gradually resolve but can be slow (4–6 months). Corticosteroids have been added for an anti-inflammatory response, but there was little benefit which might point to a different pathogenetic mechanism.NSAIDs has helped to keep his AS relatively stable during the COVID-19pandemic. During the last review, the patient expressed his wishes to go back on biologic. But the question remains whether he will a have a recurrence of panniculitis or not?Case report - Key learning points1/Anti-TNF inhibitors sometimes cause secondary autoimmune conditions like cutaneous vasculitis, lupus-like syndrome, but there is not enough data regarding biosimilar induced autoimmunity.2/This case illustrates the high importance of having a tissue diagnosis. (whenever there is an issue, the diagnosis would be in the tissue).3/There is still uncertainty whether a recurrence of panniculitis might occur or not if the patient went again on biologics.