Nodular Panniculitis Research Articles

Understanding Erythema Nodosum

ABSTRACT Erythema nodosum is a common form of acute nodular septal panniculitis commonly found on the anterior tibial extensor surfaces. Although diagnosis is typically made based on clinical presentation, confirmation is made through biopsy that includes a portion of subcutaneous fat. Erythema nodosum is usually self-limiting, with routine treatment consisting of a conservative approach of supportive measures. Additionally, erythema nodosum is recognized as a cutaneous manifestation of systemic conditions, including inflammatory bowel disease. Dermatology providers should investigate the possibility of underlying inflammatory bowel disease and consider referral to a gastrointestinal specialist when appropriate. Therefore, the purpose of this article was to ensure providers have a thorough understanding of the diagnosis to determine appropriate treatment and identify when critical referrals are warranted. Utilizing an evidence-based, multidisciplinary approach that addresses both the gastrointestinal manifestations of inflammatory bowel disease and the cutaneous symptoms of erythema nodosum will improve both patient outcomes and satisfaction.

Nodular pyogranulomatous panniculitis due to Leishmania infantum infection in a domestic ferret (Mustela putorius furo)

Leishmaniosis is a vector-borne disease caused by different Leishmania species and transmitted by phlebotomine sand flies under natural conditions in Europe. Scientific information related to Leishmania infantum in dogs is extensive, where less information is available in cats and other companion animals. Recently, first clinical cases of L.infantum infection in domestic ferrrets (Mustela putorius furo) have been described. However, clinical information on leishmaniosis in this species is limited A 15-month-old male neutered domestic ferret was presented with chronic weight loss and the presence of coalescent, erythematous and firm subcutaneous nodules in the ventral abdominal subcutis. A fine-needle aspiration of these nodules was performed and the cytological examination revealed a granulomatous inflammation with the presence of macrophages contained a number of oval organisms with an eccentric nucleus and pale cytoplasm, compatible with Leishmania spp. amastigotes compatible with Leishmania spp. amastigotes. The nodules were surgically excised and histological examination showed a severe multifocal pyogranulomatous panniculitis. Specific immunohistochemistry and qPCR for L. infantum from excised nodules were positive. Additionally, L. infantum was cultured and isolated from the nodules by a fine-needle aspiration. An in-house Western Blot test for L. infantum was performed in serum sample and a positive result was obtained. This is the first reported case of nodular pyogranulomatous panniculitis due to L. infantum infection in a domestic ferret. Further studies are necessary to determine the relevance of domestic ferrets in the transmission of leishmaniosis. The description of new clinical forms of the disease is important as it can assist veterinarians in identifying these new clinical presentations.

Subacute nodular migratory panniculitis, a rare presentation of a rare disease: a case report

Panniculitis refers to the inflammation of the subcutaneous fat. Subacute nodular migratory panniculitis (Aka Vilanova disease) is a rare type of panniculitis seen predominantly in women. Clinically, it closely resembles erythema nodosum but is often unilateral as opposed to the bilateral involvement in erythema nodosum. Triggering factors include infections, drugs, thyroid disorders, pregnancy, or malignancies. We report a rare case of a 52-year-old female who was a known case of hypothyroidism and presented with sudden onset of red colored painful lesions with raised temperature over both lower limbs. Hematological evaluation was unremarkable except for raised erythrocyte sedimentation rate. Histopathological examination of the lesion showed septal panniculitis with giant cells, suggestive of subacute nodular migratory panniculitis. The patient responded very well to treatment with capsule indomethacin.

Miscellaneous annular diseases.

Annular lesions represent a unique macro-morphologic pattern in various skin disorders that may be found in pityriasis rotunda, elastosis perforans serpiginosa, subacute nodular migratory panniculitis, keratolysis exfoliativa, neutrophilic eccrine hidradenitis, hemophagocytic lymphohistiocytosis, and intentionally induced annular lesions. This group is highly heterogenous and variable in clinical presentation. Whereas some are benign self-limiting disorders like pityriasis rotunda, others such as hemophagocytic lymphohistiocytosis follow a chronic course or have a potential of being life-threatening. Epidemiology, pathogenesis, histopathology, clinical presentation and diagnosis, differential diagnosis, and treatment are discussed.

Autoimmune Diseases and Retina

Autoimmune diseases are a group of diseases that can result in organ-specific and/or systemic (systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis,...) anatomical deformation and loss of function as a result of the body's immune system attacking its own antigens under the influence of genetic and environmental factors. The eye is a potential target for complications related to autoimmunity, and depending on the severity of the immune response, vision-threatening problems can be observed. Immune complexes accumulate in and around the vessel walls as a result of humoral immunity, in which the autoantibody-related complement system is activated, and cellular immune response can lead to retinal vasculitis, vaso-occlusion, retinal hemorrhage, retinal ischemia, ischemic optic neuropathy, and inflammation of periorbital tissues. Therefore, the role of ophthalmologists in disease management is important in diagnosing, investigating, and treating ocular symptoms in a timely manner. Early diagnosis and treatment can play a critical role to decrease the risk of irreversible immunological damage to the retinal tissue. A multi-disciplinary approach for complete management and evaluation is needed in this disease group. This study aimed to provide a detailed review of the current clinical perspective for the diagnosis, workup, and treatment of autoimmune diseases with retinal manifestations. Systemic lupus erythematosus, Polyarteritis Nodosa, Dermatomyositis, Scleroderma, Wegener's Granulomatosis, Churg-Strauss Syndrome, Takayasu Arteritis, Susac Syndrome, and Nodular Panniculitis are discussed under this heading.

Canine sterile nodular panniculitis associated with digestive disease: A report of 4 cases

Four dogs were presented for sterile nodular panniculitis , confirmed by cytological and histopathological exams of skin biopsies. The panniculitis was associated in two dogs with a pancreatitis and in two other dogs with a tumoral process (one pancreatic adenocarcinoma and one gastrointestinal stromal tumour). Sterile nodular panniculitis secondary to a digestive disease is rarely reported in dogs and, to our knowledge, has never been described with an intestinal tumour. Quatre chiens sont présentés pour une panniculite nodulaire stérile, confirmée par des examens cytologiques et histopathologiques de biopsies cutanées. Cette panniculite est associée à une pancréatite chez deux chiens et à un processus tumoral (un adénocarcinome pancréatique et une tumeur gastro-intestinale stromale) chez les deux autres chiens. Une panniculite nodulaire stérile secondaire à une maladie digestive est rarement rapportée chez le chien et, à notre connaissance, n’a jamais été décrite associée à une tumeur intestinale.

Polydioxanone thread insertion in combination with radio frequency treatment does not exhibit synergistic efficacy: Animal study with pigs.

Polydioxanone (PDO) thread insertion and monopolar radio frequency (RF) treatment are two common antiaging modalities. The efficacy and safety profile of PDO in combination with RF treatment is unknown. To investigate pathological changes in skin in response to PDO+RF treatment in an animal model. PDO threads were implanted into the skin of young white domestic pigs. RF treatment was performed on the PDO insertion sites 2weeks after the PDO procedure. Skin biopsies were taken at 6 and 12weeks after PDO for histological examination. Both PDO and PDO+RF treatments induced the fibrous granular formation surrounding the PDO threads. There were more exaggerated inflammatory responses such as development of nodular panniculitis and adipocyte necrosis in the skin at 6weeks after PDO+RF as compared with PDO alone, which was largely resolved at 12weeks. All treatments led to thickened and replicated interlobular septa, many of which were connected to the collagenous network in dermis. In all treatment groups, the cross-sectional areas of the dermal collagenous bundles were significantly increased at both endpoint times as compared with the baseline level. PDO+RF treatment did not lead to increases in neocollagenesis as compared with PDO or RF treatment alone. Our data showed that RF and PDO induced comparable levels of collagen remodeling in the skin. PDO+RF treatment did not exhibit evident synergistic effects of derma collagen remodeling but rather amplified the inflammatory responses in the skin. Therefore, combined treatment is not recommended.

Not Just Uterine Adenocarcinoma—Neoplastic and Non-Neoplastic Masses in Domestic Pet Rabbits (Oryctolagus cuniculus): A Review

With increasing numbers of pet rabbits living out their natural lifespan, rabbit oncology is stepping more and more into the limelight. On the other hand, rabbit tumors are less covered in recent editions of textbooks of veterinary pathology than before. We present 1238 cases with neoplastic and non-neoplastic masses in rabbit tissue, submitted from 2008 to 2019, supplemented by a review of the literature on neoplasms in rabbits. Cutaneous masses comprised 47% of submissions. Trichoblastoma was by far the most common skin neoplasm, and nodular suppurative panniculitis was the second most frequent skin nodule in this series. Epithelial as well as mesenchymal cutaneous neoplasms can be virally induced in rabbits (eg, Shope papilloma, myxomatosis) but were infrequent in the current cases. Mammary neoplasms comprised 21% of submitted masses and 94% of these had histologic features of malignancy. Tumors of the female reproductive tract were responsible for 9% of biopsies and were predominantly uterine adenocarcinoma. Polypoid proliferation of rectal mucosa was the most common lesion in the alimentary tract. A broad spectrum of other neoplasms was described, including sarcomas at vaccination sites and ocular posttraumatic sarcomas, comparable to lesions described in cats.

Imaging of idiopathic nonsuppurative nodular panniculitis of breast.

Imaging of idiopathic nonsuppurative nodular panniculitis of breast.

Multiple calcifications in the skin and viscera: a case report

Nodular panniculitis, also known as Weber-Christian disease, is a nonsuppurative inflammatory disorder that affects the adipose tissue (1). It presents as symmetrically distributed subcutaneous nodules which are often accompanied by abdominal pain and vomiting as well as systemic symptoms that include fever and malaise. It is classified into dermatologic and systemic types based on the organ systems involved. In this article, we present a rare case of multiple calcifications in the skin and viscera. This is followed by a discussion of the diagnosis and treatment.

Idiopathic nodular panniculitis of an exceptionally large size in a German Shepherd dog: a case report

An unusual occurrence of idiopathic nodular panniculitis of an extremely large size was recognised in a German Shepherd dog. The dog was presented with a large subcutaneous nodule at the latero-ventral aspect of the abdomen on the left side of the animal. The lesion grossly appeared as a large tissue mass resembling some kind of adipose tissue tumour such as lipoma or liposarcoma. However, the histologic appearance of the tissue mass was indicative of nodular panniculitis as reflected by diffuse cellular inflammatory reaction on a wide area of adipose tissue. The cellular infiltrate was mainly dominated by lymphocytes together with scattered histiocytes, plasma cells and neutrophils. The interlobular septa were greatly thickened by massive infiltration of inflammatory cells and septal fibrosis.

Bilateral ptosis as first presentation of cytophagic histiocytic panniculitis: a case report

BackgroundCytophagic histiocytic panniculitis (CHP) is a rare form of nodular panniculitis that may progress to panniculitis-like T-cell lymphoma. We report a case of CHP that first manifested as bilateral ptosis, which is the first reported case of this presentation.Case presentationA 25-year-old woman without medical history was referred to the neurology department of our hospital for evaluation of bilateral ptosis. Three months previously, she suddenly complained of bilateral ptosis without apparent cause. Simultaneously, non-painful tender subcutaneous nodules and eschar-like skin lesions were observed on her extremities and trunk. A diagnosis of CHP was made based on skin biopsy from the left thigh showing lobular panniculitis, vasculitis, and adiponecrosis, with infiltration of inflammatory cells, including lymphocytes, histiocytes, and phagocytic histiocytes. Her condition continued to worsen with corticosteroid and immunosuppressive agent (thalidomide) treatment. Significant improvement was noticed after three cycles of chemotherapy of THP-COP (pirarubicin, cyclophosphamide, vincristine, and prednisolone).ConclusionsCHP is a rare condition whose clinical presentation may include bilateral ptosis and biopsy is required for diagnosis of CHP.

Clinical application of dapsone in two cases of canine sterile nodular panniculitis

This report describes the different responses to dapsone treatment in two cases of sterile nodular panniculitis (SNP). Two dogs were presented with ulcerative skin lesions, painful and erythematous papules, and nodules. History and physical examination revealed systemic signs such as pyrexia, lethargy, depression, and anorexia, in addition to ulcerated and ruptured nodules on the skin. The dermatological diagnostics included clear taping, trichogram, skin scraping, impression smears, fungal and bacterial cultures, and histopathology and special stainings of multiple punch biopsies obtained from the skin lesions. Based on the clinical and histopathologic findings, the absence of microbiological infection, and the positive response to immunosuppressive therapy, both the dogs were diagnosed with SNP. Although both dogs had been treated with various immunosuppressive drugs including prednisolone, cyclosporine, azathioprine, and triamcinolone, therapy was switched to dapsone due to recurrent dermatological signs and presumed steroidinduced hepatotoxicity. The clinical responses to dapsone were opposite in the two cases. In the first case, combination therapy with prednisolone and cyclosporine was effective in attenuating ulcerative lesions, while dapsone alone did not control the clinical signs. In contrast, in the second case, the therapeutic response to the common immunomodulatory drugs such as prednisolone, triamcinolone, and azathioprine was inadequate. Interestingly, dapsone alone was effective in controlling the clinical signs without causing undue side effects. Although the usefulness of dapsone for the treatment of canine SNP is unknown, it may be considered in mild to moderate cases of SNP when the use of steroids is not recommended due to its low efficacy or side effects.

Minocycline successfully treats exaggerated granulomatous hypersensitivity reaction to Mw immunotherapy.

Mycobacterium W (Mw) vaccine has been found to be effective in the treatment of leprosy and warts. Despite increasing use of Mw immunotherapy, data on its safety is limited. We report a series of eight patients who developed persisting injection site granulomatous reaction following Mw immunotherapy and were successfully treated with minocycline. Eight patients with persistent nodular swelling at the site of Mw injections were identified. Seven of them had received Mw immunotherapy for cutaneous warts and one for verrucous epidermal nevus. The lesions were firm, erythematous, succulent, non-tender nodules confined to the sites of Mw vaccine injections. In 6 of these patients nodules also involved the previously injected areas. Skin biopsy from all patients showed eosinophil rich inflammation admixed with histiocytes and lymphocytes. In addition granulomas were seen in all with septal and nodular panniculitis in four patients. Broken and granular acid-fast bacilli were identified in two cases. All patients were treated with oral minocycline 100 mg/day for a mean of 9 weeks and showed good clinical response. Granulomatous reaction is a rare but significant adverse effect of Mw immunotherapy at cosmetically and functionally imperative sites. Oral minocycline appears to be effective therapy in this situation.

Canine sterile nodular panniculitis: a retrospective study of 39 dogs.

Canine sterile nodular panniculitis (SNP) is an inflammatory disease of the panniculus that is typically managed with immunomodulatory or immunosuppressive treatments. It has been reported to be a cutaneous marker of an underlying systemic disease. To assess the presence or absence of concurrent systemic diseases associated with canine SNP and to document breed predispositions. Thirty nine dogs presented to a veterinary teaching hospital from 1990 to 2012 which met inclusion criteria. Inclusion in this retrospective study required a diagnosis of SNP via histopathological analysis and negative special stains for infectious organisms. Breed distributions of affected dogs were compared to all other dogs examined at this hospital during the study period. Correlations between the histological pattern of panniculitis and the histological presence of dermatitis, clinical presentation of lesions, dog breed and therapeutic outcomes were assessed. Australian shepherd dogs, Brittany spaniels, Dalmatians, Pomeranians and Chihuahuas were significantly over-represented, but correlations between inflammatory patterns of panniculitis and other histological and clinical factors were not identified. Based on the information available in medical records, 32 dogs (82.1%) had no concurrent systemic diseases identified. Four dogs had concurrent polyarthritis, which may be related to SNP through unknown mechanisms. This study identified several novel breed predilections for SNP; it failed to find any clear correlations with associated systemic diseases other than polyarthritis. The histological inflammatory pattern of SNP does not predict therapeutic outcome.

CASE REPORT: LOW DOSE CYCLOSPORINE COMBINED KETOCONAZOLE CURES A DOG OF STERILE NODULAR PANNICULITIS

An eight-year-old neutered male Cocker Spaniel with multiple subcutaneous masses on the right flank was presented to National Taiwan University Veterinary Hospital. The masses were excised and submitted for histopathologic evaluation and bacterial culture. A diagnosis of severe panniculitis was made and no microorganism was identified with bacterial culture. The patient did not respond well and showed significant side effects from prednisolone therapy. Later, low-dose cyclosporine was used instead and the lesions resolved. Complete remission was observed when ketoconazole was added in order to increase the blood concentration of cyclosporine in the patient. There were no adverse side effects noted during this combination therapy. The patient has remained free of the disease at the time this report was written. In conclusion, low-dose cyclosporine combined with ketoconazole therapy is safe and effective for treating sterile nodular panniculitis, when glucocorticoid does not provide an adequate clinical result.

Locoregional Multiple Nodular Panniculitis Induced byPseudomonas aeruginosaWithout Septicemia

Pseudomonas aeruginosa-induced locoregional multiple nodular panniculitis without septicemia is an underreported condition, with only 3 cases reported to date. We report 3 new cases of P aeruginosa-induced multiple nodular panniculitis without septicemia and describe common features among all 6 cases, thus providing the first description, to our knowledge, of the natural history and potential predisposing factors for this entity. Median age of the 6 patients was 74 years (range, 54-84 years). Patients had inflammatory nodules on a lower limb (n = 6) that were unilateral (n = 6) and had no fever (n = 5). Blood cultures were negative (n = 5). Skin biopsy specimens revealed panniculitis (n = 5), with skin cultures positive for P aeruginosa (n = 6). Skin nodules resolved with systemic antibiotics (n = 5). The comorbidities recorded were type 1 or 2 diabetes mellitus (n = 5), overweight (n = 3), and combined locoregional anatomical changes in the lower limbs (n = 5). Local skin injury, which constituted the portal entry, was present in all cases, especially leg ulcers (n = 3). We describe P aeruginosa-induced locoregional nodular panniculitis as a distinct entity. This should be investigated in elderly, diabetic, overweight patients with inflammatory nodules on a lower limb associated with locoregional anatomical changes and skin injury, with the optimal antibiotic regimen introduced as rapidly as possible.

Weber-Christian disease: ultrasound can see it

Weber-Christian disease, also known as idiopathic relapsing febrile nodular non-suppurative panniculitis, is a rare inflammatory disorder of the subcutaneous tissue characterized by recurrent nodules often associated with constitutional symptoms, in particular pain and fever. A 50-year-old female patient underwent ultrasound examination of the soft tissues because of relapsing painful subcutaneous nodules of the left arm, accompanied by fever. Ultrasonography showed subcutaneous nodules suggestive of panniculitis. An ultrasound-guided biopsy was performed. The ultrasound-guided biopsy from the nodules with mixed echostructure revealed lobular panniculitis with a mixed cell infiltrate, consistent with Weber-Christian disease, after clinical and pathological exclusion of several differential diagnoses. Recurrent painful subcutaneous nodules associated with fever necessitate a careful medical history and thorough physical examination. Ultrasound can be useful to formulate the hypothesis of panniculitis. Histological examination of a ultrasound-guided biopsy of a nodule with mixed echostructure is needed to confirm the diagnosis. Weber-Christian disease remains a diagnosis of exclusion, when no other cause for the lobular panniculitis can be identified.

Continuous perioperative apomorphine in deep brain stimulation surgery for Parkinson's disease

Background. Patients with Parkinson's disease (PD) deprived of dopaminergic medication to facilitate awake testing during the deep brain stimulation (DBS) procedure are at increased risk of neurologic deterioration.. The aim of this survey was to demonstrate the safety of subcutaneous apomorphine treatment for reducing surgery-related neurologic deterioration in patients undergoing DBS surgery for PD. Methods. Ninety-two patients who underwent DBS surgery for PD between 11/2007 and 10/2011 in our department were retrospectively analyzed for this survey. Demographic data, apomorphine dosage, side-effects and need of ICU/IMC stay were collected and analyzed. Results. Seventy-two out of 92 patients (78.3%) received apomorphine treatment; main reason for omission of treatment was intolerable nausea (16/92, 17.3%). Apomorphine treatment was well tolerated and the most common side effect was nodular panniculitis. No severe complications were observed. No patient required ICU/IMC stay related to dopaminergic deprivation. Conclusions. Perioperative withdrawal of dopaminergic medication in PD patients leads to an increased risk of neurologic and respiratory deterioration during DBS procedures. These complications can likely be tempered using perioperative subcutaneous apomorphine as a substitute. Our 5-year experience indicates a reduction in postoperative neurologic deterioration and ICU/IMC stay need. We consider perioperative apomorphine safe during DBS surgery for PD.

The presenting manifestations of subcutaneous panniculitis-like T-cell lymphoma and T-cell lymphoma and cutaneous γδ T-cell lymphoma may mimic those of rheumatic diseases: a report of 11 cases

This study aims to investigate the association between subcutaneous panniculitis-like T-cell lymphoma (SPTCL) or cutaneous gamma/delta T-cell lymphoma (CGDTCL) and a variety of manifestations that mimic autoimmune disorders. A retrospective chart review was made for 11 patients who were initially diagnosed as autoimmune diseases but finally turned out to be SPTCL or CGDTCL. Eleven patients were initially diagnosed with erythema nodosum, nodular panniculitis, lupus erythematosus profundus, systemic vasculitis, dermatomyositis, or pyoderma gangrenosum. The interval between presenting symptoms and the diagnosis of lymphoma was 17.5 (range, 3-84) months on average. Nearly all cases had multiple subcutaneous nodules or plaques that were most commonly distributed on the extremities and trunk. Fever was the primary accompanying sign (9/10), followed by lymphadenopathy (6/11), splenomegaly (5/11), and hepatomegaly (3/11). Two patients developed hemophagocytic syndrome. A total of 26 biopsies involving multiple anatomic locations were performed. Antirheumatic therapy including steroids and immunosuppressive agents administered before the identification of T-cell lymphoma revealed unsustainable therapeutic effect. In contrast, seven cases gained partial response after chemotherapy, while the remaining four cases died with disease progression and disease-associated severe infections. SPTCL and CGDTCL are rare and heterogeneous which may resemble those rheumatologic diseases that are characterized by inflammation involving the skin or subcutaneous fat tissue. The diagnosis relies on the constellation of disease-specific pathologic, immunophenotypic, and T-cell receptor gene rearrangement tests. In the context of an ambiguous clinical picture demonstrating inconsistency with the initial diagnosis of benign autoimmune diseases, repeated excisional biopsies of the subcutaneous lesions may be required to uncover the underlying lymphoma.