Subcutaneous fat necrosis of newborn - A rare case report of lobular panniculitis in a neonate

Subcutaneous fat necrosis of newborn is a rare cutaneous disorder affecting neonates. It usually presents as subcutaneous nodules or plaques, within the first few weeks of life, following an eventful delivery. It is characterized by hypercalcemia, which may present with lethargy, irritability, hypotonia and dehydration, mimicking sepsis. Histopathology is proven to be the gold standard in diagnosis with characteristic lobular panniculitis, mixed inflammatory cell infiltrate and radially arranged crystals. This needs to be differentiated from other causes of lobular panniculitis, as early diagnosis and treatment to prevent long‑term complications are advocated. Education of parents regarding the disease and danger signs of hypercalcemia and weekly monitoring of serum calcium is recommended. Treatment based on rehydration, dietary vitamin D and calcium restriction, Furosemide and prednisolone are considered. We have discussed a case of subcutaneous fat necrosis, in an 8-week-old male baby.Key Messages: Subcutaneous fat necrosis is an important differential in neonates presenting with palpable subcutaneous nodules, along with sclerema neonatorum. Severe complications like hypercalcemia should be detected early and managed aggressively to prevent morbidities and mortalities associated with it. Symptomatic management, use of calcium lowering drugs and regular monitoring of calcium levels are recommended.

Lobular panniculitis as a manifestation of pancreatitis. Difficulties in diagnosis

The clinical picture of lobular panniculitis associated with damage to the pancreas can vary widely, accompanied by damage to the joints and internal organs, which complicates the diagnosis of the disease. A clinical observation of a torpid course of lobular panniculitis with total damage to organs and systems is presented, which clearly illustrates the difficulties of differential diagnosis and therapy that arise in real therapeutic practice.

Comorbidity in patients with lobular panniculitis-lipodermatosclerosis

Lipodermatosclerosis (LDS) is one of the variants of lobular panniculitis. The onset of LDS falls on the age of 50–60 years, when many patients already have comorbid pathology requiring complex therapy, which affects the course, the choice of treatment and prognosis of LDS, as well as the quality of life.Objective: to study the structure and frequency of comorbid conditions in patients with LDS.Patients and methods. 53 patients (3 men and 50 women), 18–80 years old, with a verified diagnosis of LDS were included, all of them had an average follow up of 10 years (they were observed in the V.A. Nasonova Research Institute of Rheumatology). The duration of the disease ranged from 2 weeks to 20 years. During clinical examination, the localization, prevalence, color and number of affected skin areas and sub cutaneous fat were determined. The intensity of pain on palpation of the node was assessed using a visual analogue scale (VAS). Laboratory and instrumental research included: blood and urine tests, computed tomography of the chest and ultrasound Doppler of the lower extremities with registration of the linear blood flow velocity in the affected veins (femoral, popliteal, posterior tibial, foot veins). Clinical, laboratory and instrumental examination of patients was carried out 2 times a year. The CIRS and Charlson indices were used to assess the relationship between comorbid pathology and LDS.Results and discussion. Most patients (60.3%) were women with increased body weight (91.5±21.8 kg). Depending on the duration of the disease, the main variants of the LDS course were: acute (<3 months), subacute (3–6 months), and chronic (>6 months). Skin changes were associated with polyarthralgia (34%) and/or myalgia (22.6%), mainly on the side of the affected limb. In 16 patients, an increase in ESR, on average 23.8±7.8 mm per hour, was detected, in 7 patients, including 4 with an acute course of LDS, – more than a threefold increase in the level of CRP. No comorbid diseases had 17 patients, 64.7% of them were under 50 years and had an acute course of LDS (p=0.02). In 68% of patients, mainly with chronic LDS, the following concomitant diseases was recorded: chronic venous insufficiency (CVI; in 67.9%); exogenous constitutional obesity (in 60.3%); rheumatic diseases (45.2%), including osteoarthritis (75%), rheumatoid arthritis (17%), antiphospholipid syndrome (8%), and arterial hypertension (39.6%). Most patients had 1 concomitant disease, and almost one fifth of patients had 2 concomitant diseases. The proportion of patients with 3 comorbid pathologies was 11.1%, with 4 – 8.3% and with 5 – 5.5%. When assessing the Charlson index, a 10-year survival rate of >90% (index values from 0 to 2 points) was observed in 66% of patients, 53–77% (3–4 points) – in 26.4% and <21% (≥5 points) – in 7.5%. There was correlation between the comorbidity index and the age of patients (r=0.8, p<0.05); no association with the duration of LDS was found (r=0.3, p=0.2). Patients over 61 years had ≥1 comorbid disease. The average CIRS index for this group was 4.2±0.3 points (0–10), in most patients (45.2%) it was <5 points. Analysis of the Charlson and CIRS scales confirmed their statistically significant relationship (r=0.5, p=0.0000001).Conclusion. In patients with LDS, a high incidence of comorbid pathology was noted. Interdisciplinary approach with interaction between doctors of different specialties is required for treatment of these patients.

A rare case of traumatic panniculitis

Panniculitis is a rare disorder which usually affects the organ and tissue which are abundant in fat cells. It causes fatty degeneration of the fat cells. Cutaneous panniculitis can be mistaken for other skin and subcutaneous lesions and the diagnosis is usually made histologically. We report a 18 yr old female presented with multiple subcutaneous nodules on right cheek since six months and with history of trauma two years back associated with facial asymmetry and histological examination revealed lobular panniculitis of traumatic etiology.

Necrotizing panniculitis secondary to primary cutaneous localized mucormycosis

Primary cutaneous mucormycosis is a rare entity that affects more frequently extremities of immunosuppressed patients and may be gradual in onset or fulminant. An 83-year-old female with diabetes mellitus presented a nodular lesion in the forearm, which had progressed during one month. Clinically, as the lesion was indolent and followed a linear trajectory, a superficial phlebitis was suspected but later ruled out. Skin blood cultures were negative. Skin biopsy showed a necrotic panniculitis with isolated ghost adipocytes and presence of irregularly branched hyphae involving dermis and some vessels that could be stained with PAS and Grocott, thus leading to the diagnosis of primary cutaneous localized mucormycosis. This case is noteworthy as indolent course in primary cutaneous mucormycosis with vascular involvement is rather rare. Even with a negative culture, R. Variabilis is a candidateetiologic agent as it usually presents a chronic evolution. Histopathologically, most panniculitis related to fungal infection are reportedas pancreatic panniculitis mimickers. In our case, only scarce ghost adipocytes were found and the main histopathological findings were a lobular panniculitis with vasculitis and an extensive basophilic necrosis. Thus, these histopathologic findings should raise suspicion of infection related-panniculitis, and PAS and Grocott stainings should be performed to rule out fungi.

AB1062 LIPODERMATOSCLEROSIS AS A TYPE OF LOBULAR PANNICULITIS: THE EFFECTIVENESS OF NON-PHARMACOLOGICAL TREATMENT METHODS

Background:In medical practice lobular panniculitis-lipodermatosclerosis (LDS) is becoming more and more common. It is manifested by degenerative-dystrophic changes in subcutaneous fat (SCF) and occurs more often in middle-aged women affected by chronic venous insufficiency.Objectives:to evaluate the effectiveness of mesotherapy (MT) and shockwave ultrasound therapy (UST) for LDSMethods:among 539 patients referred to the V.A. Nasonova Research Institute of Rheumatology with the referral diagnoses of erythema nodosum or panniculitis 8.5% (46) of patients (44 women, 2 men) aged 18 to 82 with overweight (32) LDS with the disease duration of 11,8±6.4 months was verified. Patients were randomized into two groups of 23 patients each: group I received daily MT (10 sessions) therapy with drugs that have antioxidant, anti-inflammatory, lymphatic drainage and lipolytic effects, and 3 MHz UST of the node area twice a week (5 sessions). In group II MT was performed daily with 9% Natrii chloridum solution at a dose comparable to group I. The control methods included general clinical examination (characterization of induration on the lower legs with an assessment of the effect of pain pressing according to visual analogue scale (VAS pain), general blood and urine tests and ultrasound with elastography (USE) of the compaction. The main stages of control: initial (T0), after 14 days (T1), 1 month (T2) and 3 months (T3).Results:before treatment 38 patients with LDS demonstrated asymmetric (83%) inflammation of SCF of the lower legs (100%) on its medial surface (91%). LDS regressed faster with normal body mass index (p = 0,04). In all patients of group I, after a course of physiotherapy a positive trend was registered, that is a decrease in VAS pain intensity (T0 50±18 mm; T1 35±11 mm), decrease in diameter (T0 6±2.2 cm; T1 4.5±1, 7 mm) and color intensity of the node (p<0.002), SCF thickening which results in “lumping” with macrovascularization according to USE, and decrease in ESR and CRP. In 44% of cases the treatment effect increased to T2 (p <0.05). After 3 months of observation, 15 patients required a second course of physiotherapy. In group II a positive clinical effect was registered for T2 in 14 patients (60.8%) and for T3 in 19 patients (83%) (p<0.05). Over the entire observation period LDS recurrence was registered in 19 patients (41%), the median of recurrence was 3 [1; 6] months, mainly in patients of group I. Recurrence was associated with node fusion into conglomerates (OR 4.33, 95% CI 1.05-17.8; p = 0.037). MT and UST were tolerated well, no side effects were detected.Conclusion:the use of MT with 9% Natrii chloridum solution allowed us to achieve positive dynamics in patients with LDS, which significantly reduced the cost of treatment. Further studies are needed to evaluate the significance of these techniques.Disclosure of Interests:None declared

AB1015 FEATURES OF CLINICAL AND LABORATORY ACTIVITY IN IDIOPATHIC LOBULAR PANNICULITIS.

Background:The pathological process of idiopathic lobular panniculitis (ILP) comes from disorganization of the adipose tissue which leads to its fibrosis and atrophy. It is assumed that the disease is of immunopathological nature, as evidenced by disorders of lipid peroxidation, high CIC, excess production of leptin (LEP), IL-2 and TNF. The latter is considered a key cytokine involved in the development of the disease.Objectives:to establish the relationship between the clinical picture and immuno-inflammatory parameters (CRP, LEP and TNF) in patients with ILP.Methods:We examined 67 patients (9 men, 58 women) with the ILP diagnosis verified in the Institute in 2007-2017. The age of patients ranged from 20 to 76, the average duration of the disease was 78.91[48.50] months. In addition to general clinical examination we performed immunological, histological studies, computed tomography of the chest, tuberculin samples. To determine the body mass index of patients, the values of the Quetelet index (QI) were used.Results:The disease was found in all age groups, but more than half of the patients (57%) were in the most active working age of 45-60. ILP started with painful induration of various localization, except for the face, and increased temperature reaction of the body. The mean value of QI 24.10±12.01 cm/kg corresponded to normal body weight (p=0.180). 41 patients (61.19%) demonstrated normal QI and preobesity at the age before 45 in 30.3% of cases (p=0.36). Obesity of degree II and III was recorded for 7 patients (10.44%). QI correlated with the age of patients (r=0.43, p<0.05). ESR correlated with VAS pain intensity (r=0.29, p<0.05), lesion area (r=0.50, p<0.05), temperature increase (r=0.68, p<0.05,) and CRP level (r=0.68, p<0.05). The concentration of CRP correlated with VAS pain intensity (r=0.46, p<0.05), lesion area (r=0.57, p<0.05), stage II node (r=0.41, p<0.05) and TNF–α concentration (r=0.32, p<0.05). The increase of the last indicator had a direct correlation with stage II of the node (r=0.41, p<0.05,) and with the level of LEP (r=0.28, p<0.05), and an inverse correlation with the number of nodes (r=-0.24, p<0.05). The level of LEP increased in 35 patients (52.23%), had a direct correlation with QI (r = 0.46, p<0.05), the affected area (r = 0.31, p<0.05), the concentration of CRP (r=0.36, p<0.05) and an inverse correlation with the number of nodes (r = -0.33, p<0.05).Conclusion:it is obvious that in case of ILP there is a need to increase knowledge about the markers of inflammatory activity (ESR, CRP, TNF–α and LEP) which correlated with the area of the lesion, VAS pain intensity and temperature increase.Disclosure of Interests:None declared