Liquefying panniculitis associated with intraductal papillary mucinous neoplasm

A 64-year-old man presented with a weight loss of 10 kg over 1 year and insomnia. CT scan revealed an approximate 3.0 cm homogeneous low-density mass in the head of pancreas. Tumor markers including CEA, CA125, AFP and CA199 were not elevated. The patient’s serum levels of amylase, lipase and calcium were normal. The patient received the pancreatoduodenectomy on 3 March 2010 and the postoperative pathology gave a definite diagnosis of IPMN of the pancreas (Figure 1). 0.1 mg of octreotide injected subcutaneously every 8 h was postoperatively administered to suppress pancreatic secretion and decrease the risk of pancreatic fistula. On postoperative day 2, on the right lower limb skin a localized erythema appeared which slowly became larger, but the subcutaneous lesion did not bulge onto the surface of the skin. Subsequently the localized red-brown erythema was present over the right upper leg and knee joint. On postoperative day 5, the examination showed multiple subcutaneous inflammatory nodules on the legs and the buttock (Figure 2). Some of the larger lesions were necrotic and exuded a viscous fatty material, accompanied by general malaise. On postoperative day 7, we invited the dermatologist to examine the patient and made a diagnosis of liquefying panniculitis. According to the report from the former literature, the octreotide was effective to liquefying panniculitis. We increased octreotide intravenous infusion to 0.6 mg every day and simultaneously used the Medrol (glucocorticoid, 20 mg/24h), Ulinastatin (protease inhibitors) and antibiotics. No new nodules appeared and the original nodules did not change. However, the patient appeared anastomotic leakages and the wound grew worse. Drainage pipes discharged some yellow oily mucus substance. The patient had to receive the second operation on 1 April 2010. Introperatively, we found the pelvic cavity filled with brown oily necrotic liquids of about 50 mL. The postoperative pathology showed the necrosis of omental fat tissue. Unfortunately, several days later, new erythemas spread and scattered over his right thigh and right hand wrist. The former nodules grew larger again. The patient died of multiple organ failure on 27 April 2010.