CPC03 A case of pancreatic panniculitis as the first presentation of pancreatic adenocarcinoma

Abstract

Pancreatic panniculitis is a rare complication of pancreatic disease, but in some cases it can be the presenting feature. A 72-year-old woman presented to the dermatology department with a 4-week history of an enlarging painful lesion on her right shin. Antibiotic treatment, both oral and intravenous, had not led to resolution of the lesion. She was under investigation for significant weight loss over the past 6 months and a pancreatic head lesion had been seen on imaging. She had a distant background history of breast cancer 20 years prior, but had no regular medications or active comorbidities. Examination revealed a violaceous indurated plaque with superficial ulceration and suppurative discharge measuring 7 × 10 cm on her right shin. Full-skin examination revealed no other lesions and no inguinal lymphadenopathy was appreciated. Initial differential diagnoses included primary cutaneous B-cell lymphoma or cutaneous angiosarcoma. Laboratory investigations revealed slightly raised inflammatory markers alongside raised serum amylase (239 IU L−1, reference 28–97 IU L−1) and lipase (422 U L−1, reference 8–78 U L−1) with a normal full blood count. A skin biopsy was taken for clinicopathological correlation, which revealed extensive fat necrosis and saponification with septal inflammation in keeping with pancreatic panniculitis. Microbiological investigations with bacterial skin swabs and tissue culture were noncontributory. Further abdominal investigations with endoscopic ultrasound and biopsy confirmed a diagnosis of pancreatic adenocarcinoma. Pancreatic panniculitis is rare, occurring in < 3% of all patients with inflammatory or malignant pancreatic disease. It typically presents with tender, firm suppurative nodules affecting the lower limbs with ulceration and fistulation of necrotic fat to the skin. Treatment is typically supportive, and focused on the underlying pancreatic pathology. This case highlights the importance of a broad range of differentials and clinicopathological correlation when presented with a rapidly growing painful lesion on the extremity of an older person.