Painful lower extremity nodules, pancreatitis, and polyarthritis

Presenter: Paul M. Graham
Dermatology Program: St. Joseph Mercy Dermatology
Program Director: Daniel Stewart, DO FAOCD
Submitted on: Aug 19, 2015

CHIEF COMPLAINT:  A 69-year-old Caucasian man presented with exquisitely painful nodules and marked edema of his bilateral lower legs. The nodules first appeared nine months ago and exhibited a waxing and waning course. His past medical history was significant for chronic pancreatitis of unknown origin, hypertension, gastroesophageal reflux disease, inflammatory arthritis, and hypercholesterolemia.

CLINICAL HISTORY:

Signs and symptoms:  He complained of associated painful skin nodules on his lower extremities that have been present for eight months in addition to joint pain and swelling of the metacarpalphalangeal (MCP), metatarsalphalangeal (MTP), and ankle joints.

Previous Treatment:  He was previously treated with intralesional corticosteroid injections with marginal response. High potency topical corticosteroids and non steroidal anti-inflammatory drugs were used for symptomatic pain relief.

Other information:  The patient had a history of numerous hospital admissions for pancreatitis and was being managed by Rheumatology for arthritic symptoms.

PHYSICAL EXAM:

Physical examination revealed multiple 1-3 cm ill-defined, red to brown subcutaneous nodules on the bilateral lower legs and the right inferomedial thigh. There was no overlying ulceration, drainage, or bleeding. Marked erythema and edema of the right second, third, fourth, and fifth metacarpophalangeal (MCP) joints, left first metatarsophalangeal (MTP) joint, and bilateral ankles were observed. Diffuse 2+ pitting edema was present in the bilateral lower extremities.

Figure 1. Right lower leg. Scattered 1-3.5 cm ill-defined erythematous to brown subcutaneous nodules.
Figure 2. MTP joint swelling of the right hand with overlying erythema.

LABORATORY TESTS:

Laboratory results revealed increased amylase (5,250 U/L), lipase (9,197 U/L), ESR (94 mm/h), and CRP (93.5 mg/L). Triglycerides, AST, ALT, ANA, and RF were within normal limits. CT scan of the left ankle revealed cortical bony erosion of the calcaneus. CT scan of the abdomen and pelvis revealed a 1.8 x 1.4 cm hypodense lesion within the pancreatic head with calcifications and mild proximal pancreatic ductal dilation. Ultrasonography showed no evidence of cholelithiasis. Bone biopsy specimens demonstrated mild chronic inflammation with no evidence of osteomyelitis. A serum uric acid level was found to be 4.4 mg/dL and a joint aspirate demonstrated turbid fluid with lipoid material and no evidence of crystals or organisms on culture.

Figure 3. CT scan transverse plane. Hypodense lesion within the pancreatic head with calcification.

DERMATOHISTOPATHOLOGY:

A 4mm punch biopsy of a nodule on the right leg revealed extensive lobular and septal liquefactive adipocyte necrosis with scattered neutrophils and lymphocytes. Aggregates of fine granular basophilic material were observed with prominent adipocyte degeneration and calcification.

Figure 4. H&E staining (10x): Lobular and septal liquefactive adipocyte necrosis with prominent ghost cells and fine basophilic material.

DIFFERENTIAL DIAGNOSIS:

1.   Alpha 1-antitrypsin deficiency panniculitis
2.   Erythema nodosum
3.   Nodular vasculitis
4.   Polyarteritis nodosa
5.   Lupus panniculitis


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