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Erythema nodosum is an acute nodular panniculitis, mainly affecting young women. Diverse etiologies are evoked, but the most frequent are sarcoidosis (Löfgren syndrome), streptococcal infections, yersiniosis and inflammatory enteropathies. Antalgic drugs and rest are usually adequate in this condition, which is spontaneously of favourable evolution. Treatment of the cause is open to discussion, considering their lack of effect on the evolution of erythema nodosum.

Panniculitis is a rare cutaneous manifestation of dermatomyositis (DM). The appearance of panniculitis during treatment with methotrexate (MTX) is exceptional and has only been described in 3 cases. We report a case of a 50-year-old woman suffering from DM since 1997 who was treated with corticosteroids showing favorable clinical and biological evolution. When a relapse occurred 2 years later, she was treated with higher-dose of corticosteroids in combination with a 7,5 mg weekly dose of methotrexate. The evolution was rapidly favorable. Eighteen months later, the patient had multiple subcutaneous nodules on limbs and buttocks. Anatomopathological examination showed panniculitis. There was no evidence supporting progression in DM. Prednisone dose was increased to 0.5 mg/kg/day, always in combination with MTX, without any clear signs of improvement. MTX treatment was stopped and the cutaneous lesions completely disappeared in 2 months without any relapse. This objective response lasted for 42 months. Our observation is particular given the occurrence of panniculitis in a patient undergoing treatment for dermatomyositis with methotrexate and illustrates the difficulties in the diagnosis. This entity must be known despite its exceptional nature since cutting off MTX treatment generally induces the disappearance of subcutaneous nodules.

A 72-year-old diabetic woman was referred with a painful chronic leg ulcer associated with venous and arterial insufficiency. She then developed a polymorphous skin infection due to Pseudomonas aeruginosa, with ecthyma gangrenosum, subcutaneous abscess and panniculitis of the homolateral inferior limb, without general sepsis. Although P. aeruginosa infection may induce polymorphous skin lesions, they are most often observed in immunocompromised patients following septicaemia., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Background: Pancreatic panniculitis is a rare condition that usually occurs in association with acute or chronic pancreatitis or pancreatic carcinoma. We report a case of pancreatic panniculitis revealing a pancreaticportal fistula and portal thrombosis., Case Report: A 79-year-old man was admitted for nodular panniculitis of the lower extremities without any digestive symptoms. Laboratory tests revealed very high plasma levels of amylase and lipase. A skin biopsy showed lobular panniculitis with ghost cells characteristic of pancreatic panniculitis. Rare pancreatic calcifications and portal thrombosis were seen on an abdominal CT scan and on endoscopic ultrasound examination of the pancreas. A pancreaticportal fistula was detected by endoscopic retrograde pancreatography. Finally, an endoscopic pancreatic prothesis was inserted in Wirsung's canal after failure of medical treatment (parenteral nutrition and octreotide). Skin lesions resolved and plasma pancreatic enzymes normalized., Discussion: This case report is interesting because of the lack of gastrointestinal symptoms associated with pancreatic panniculitis and the discovery of a chronic pancreatitis of uncertain etiology. This case highlights the need to screen for pancreaticportal fistula and portal thrombosis, which are often associated with pancreatic panniculitis.

Introduction: Pellagra is an exceptional disorder in France. The classical description of pellagra associates a photoinduced rash with neurological impairment and intestinal dysfunction. Without adapted treatment, the progression is fatal., Case Report: A 62 year-old women developed a photoinduced rash, composed of circular and erythematous elements with pustular edges. She also had panniculitis, peripheral neuropathy, depressive mood and diarrhea. Her medical past was marked by epilepsy treated with sodium valproate and hydantoin. Biological exams revealed lowered plasma levels of vitamins PP, B1, B6 and zinc, secondary to intestinal impairment induced by bacteria proliferating in the small intestine. The rash resolved with vitamin PP and zinc supplementation. The bacterial colonisation was improved by long-term, sequential antibiotics., Discussion: We report a rare clinical form of pellagroid rash. The rash was induced by chronic malabsorption resulting from excessive bacterial proliferation in the diverticules of the small intestine. The antiepileptic treatment could have facilitated vitamin PP et zinc deficiency. Panniculitis was related to the bacterial proliferation. We discuss in this paper the relationship between some vitamin deficiencies, their clinical manifestations and the direct role of intestinal bacterial proliferation in the cutaneous manifestations.

The inflammatory diseases of the hypodermis represent a difficult problem both for the accurate diagnosis and treatment. Several distinct etiologies and pathomechanisms can be responsible for such lesions. We present an updated panniculitis classification.

In the recent decade, two novel nosological entities among the group of panniculitis have clinically been elaborated, i.e., panniculitis associated with alpha 1-antitrypsine deficiency and histiocytic cytophagocytic panniculitis (Winkelmann). Both entities are rare and hardly aware to clinicians and pathologists till now, since they have probably been reckoned with the frame of Pfeifer-Weber-Christian's disease before. There are established reasons to qualify both syndromes as "severe" types of panniculitis, due to their prognostic uncertainty bearing the peril for fatal outcome. In this study, twelve cases of severe panniculitis cared for by the Dermatological University Department of Erlangen since the eighties, have been analyzed including two cases presenting with panniculitis of facticious or myelodysplastic origin, respectively. Based on the literature as well as clinical, histological and immunohistochemical reexamination of our cases, the significance of alpha 1-antitrypsine deficient panniculitis was considered, yet the enzymatic influences on the pathogenesis of this type of panniculitis are a matter of dispute so far. It is also questionable whether the clinical pattern of histiocytic cytophagic panniculitis that is linked with the syndrome of generalized haemophagocytosis represents, at least for distinct cases, a peculiar type of paraneoplastic inflammatory reactivity in fatty tissues, with MAC387+ phagocytic cells and UCHL1+ infiltrative cells. Since haemophagocytosis can be observed in various stages and subtypes of severe panniculitis, this phagocytic phenomenon obviously does not represent a specific marker of malignancy, but indicates a generalized disorder of the histo-phagocytic system running an often pernicious course.

We report the case of a 46-year old woman who, over a 12-year period, had 6 episodes of nodular panniculitis. Each lesion regressed and disappeared within four to six weeks. Fistulization before formation of a cupula-shaped scar was observed on two occasions. These episodes of hypodermitis seemed to be isolated when they began, but histological examination of the skin showed cytosteatonecrosis of the hypodermis pointing to a pancreatic origin. Signs of pancreatic abnormality appeared progressively: first an increase of amylasaemia concomitant with the cutaneous flares, then morphological abnormalities of the pancreatic ducts suggestive of pancreas divisum, and finally dilatation of the main pancreatic duct associated with upstream pancreatitis. No radical treatment of the pancreatic abnormality was carried out.

We report a case of calcifying panniculitis which occurred in a 67-year old woman suffering from chronic renal failure and primarily involved anticoagulant injection sites. Calcifying panniculitis is a rare condition belonging to the spectrum of calciphylaxis first described by Selye in 1962. This disease seems to imply necessarily a specific morbid background including renal failure together with calcium-phosphate metabolism impairment. Following the action of a so-called "challenger" (in the present case calcium heparinate [Calciparine], a subcutaneously administered anticoagulant drug), the lesions start as painful subcutaneous nodules soon turning into plaques of necrosis. The area involved mainly includes the abdomen and thighs, due to the preferential distribution of fat and the classical use of such regions for subcutaneous injections. In our patients, histological examination disclosed an initial involvement of subcutaneous fat vessels mimicking mediacalcosis, soon followed by calcium-phosphate deposits within interadipocyte spaces. An electron microscopy study confirmed the presence of calcium crystals within the cytoplasms of some connective tissue cells and the extracellular matrix. From a review of the literature, it seems reasonable to normalize the calcium-phosphate product by reducing hyperparathyroidism as a first therapeutic step. Then, wide surgical excision of the necrotic areas should be performed to rule out any possibility of self worsening of the lesions and provide the best chance of healing without superinfection. The use of diphosphonates on pathophysiological grounds is discussed.