Panniculitis

Question 1

Panniculitis

Answer 1

inflammation of the subcutaneous tissue, can be divided by location either septal or lobular. Easily mistaken for cellulitis

Question 2

Erythema Nodosum

Answer 2

most common form of panniculitis, females more common in 30s-40s, delayed response to an antigen

Question 3

Antigens for EN

Answer 3

bacteria, viruses, chemicals… can also be idiopathic (most common) in 55% of cases

Question 4

Common causes of EN

Answer 4

upper resp strep infections, bacterial gastroenteritis, coccidiodomycosis, Sarcoidosis, IBD

Question 5

drugs causing EN

Answer 5

estrogen, sulfa, PCN

Question 6

Clinical features of Erythema Nodosum

Answer 6

tender erythem nodules, bilaterally on shins, thighs, forearms. No ulcers. Lesions last days to weeks leaving bruise discoloration that eventually resolves

Question 7

Recurrence with EN

Answer 7

33% can recur, common annually with the idiopathic kind

Question 8

Chronic forms of EN

Answer 8

subacute nodular migratory panniculitis, erythema nodosum migrans

Question 9

lesion spreading in EN

Answer 9

start as a classic nodule and can migrate centrifugally (away from the center of the body). they demonstrate central clearing

Question 10

Pathology EN

Answer 10

prominent neutrophils, Miescher microgranulomas may be present - collection of macrophages

Question 11

Tx EN

Answer 11

assess med list, if they are on one commonly a/w EN, D/c it. Treat underlying diseases but will not shorten course of EN, bedrest w legs elevated, NSAIDs for pain

Question 12

Potassium Iodide

Answer 12

adults 150mg TID and taper up, bitter taste, dilute in juice, s/e nausea, headache, urticaria. can affect thyroid. Not for pregnancy will lead to goiter

Question 13

Alpha 1-Antitrypsin Deficiency

Answer 13

genetic error in alpha antitrypsin which controls proteases, activates lymphocytes and macrophages that attack subcutaneous fat –> panniculitis

Question 14

Pathogenesis of low alpha 1 antitrypsin

Answer 14

activates lymphocytes and macrophages that attack subcutaneous fat. Can be caused by trauma or in post partum patients

Question 15

Alpha-1 Antitrypsin Deficiency symptoms

Answer 15

very large, erythematous tender nodules and plaques on the lower legs, flank, buttocks, thighs. Ulcerations occur - deep, necrotic. Oily discharge. –> scarring, atrophy

Question 16

Pathology Alpha-1 Antitrypsin Deficiency

Answer 16

neutrophillic inflammation of the panniculus –> necrosis, destruction of fat lobules, “skip factors” where fat lobules are next to necrotic areas

Question 17

ddx Alpha-1 Antitrypsin Deficiency

Answer 17

ulcerated areas can appear as PG, trauma, infection, pancreatitis, erythema induratum

Question 18

Alpha-1 Antitrypsin Deficiency tx

Answer 18

replacing alpha 1 antitrypsin via infusion, 60mg/kg weekly x 3-7 weeks, plasma exchange, no alcohol

Question 19

Erythema Induratum

Answer 19

panniculitis commonly associated with tuberculosis but can be caused by drugs or other infections, seen in females 30-40

Question 20

Pathogenesis Erythema Induratum

Answer 20

type 4 cell mediated response to an antigen like TB, hep C, meds like propylthiouracil (PTU)

Question 21

Erythema Induratum clinical features

Answer 21

tender nodules that are erythematous to violaceous, common on the calves, commonly ulcerate, heals with a scar

Question 22

Pathology Erythema Induratum

Answer 22

inlammation of neutrophils, lymphocytes, macrophages, giant cells, vasculitis, possibly necrosis

Question 23

Erythema Induratum tx

Answer 23

treat the underlying condition if it can be identified, supportive socks, oral steroids, NSAIDs, potassium iodide

Question 24

Lipodermatosclerosis

Answer 24

sclerosing type of panniculitis on the lower legs of middle ages to older females

Question 25

pathogenesis lipdermatosclerosis

Answer 25

venous insuff, leaking fibrinogen from capillaries, fibrin cuffs around vessels interfering with o2 exchange

Question 26

lipdermatosclerosis clinical features – acute phase

Answer 26

increase warmth, pain and induration of the medial lower leg above the malleolus or the pannus of the abdomen

Question 27

lipdermatosclerosis – clinical features, chronic phase

Answer 27

sclerosis of the dermis and subcutaneous tissue that may be demarcated from adjacent normal skin, lower leg may have an “inverted wine bottle”

Question 28

lipdermatosclerosis tx

Answer 28

leg elevation, consistent compression to control the leg edema

Question 29

Pancreatic Panniculitis

Answer 29

very rare, 2% of those with pancreatitis, felt to be autoimmune but the panc. enzymes – lipase, amylase, trypsin, interplay with fat necrosis. precedes abd symptoms

Question 30

Pancreatic Panniculitis clinical features

Answer 30

subcutaneous nodules that are erythematous, edematous and painful on the legs usually but can be on the arms, chest, abd, scalp. lesions become purulent, ulcerate and discharge an oily substance

Question 31

Schmids Triad with Pancreatitis Panniculitis

Answer 31

subcutaneous nodules, polyarthritis, eosinophilia

Question 32

Pathology Pancreatitis Panniculitis

Answer 32

bx must be deep enough to contain the subcutaneous fat, early will have fat necrosis and ghost cells, late will show lipoatrophy

Question 33

dx feature characteristic of pancreatitis panniculitis

Answer 33

pancreatitis, ghost cells

Question 34

tx Pancreatitis Panniculitis

Answer 34

resolve pancreatitis

Question 35

Infection-Induced Panniculitis

Answer 35

Directly induced by an infectious agent like bacteria, mycobacteriam, borrelia, fungus, more common in immunocompromised

Question 36

Pathogenesis infection induced panniculitis

Answer 36

direct inoculation of the infectious agent

Question 37

clinical features Infection-Induced Panniculitis

Answer 37

local edema, erythema, fluctiant nodules that may ulcerate and drain,common on legs and feet

Question 38

pathology Infection-Induced Panniculitis

Answer 38

neutrophils, necrosis of lymphocytes, eccrine gland involvement, c&s is needed

Question 39

tx Infection-Induced Panniculitis

Answer 39

antimicrobials based on the c&s

Question 40

Traumatic Panniculitis

Answer 40

due to external injury 4 types: cold panniculitis, sclerosing