Abstract

Pancreatic panniculitis is a rare cutaneous manifestation of pancreatic diseases such as acute pancreatitis (AP). It can be a presenting finding or it can develop after the diagnosis. We report a 55-year-old male with a complex medical history who presented with cardiac arrest and was resuscitated. He remained intubated and hypotensive throughout his hospital course which was further complicated by bowel ischemia due to stenoses of celiac axis and mesenteric artery. He died on the fourth day of hospitalization and an autopsy was performed. External examination revealed band-like hyperpigmentation with ill-defined red-brown nodules across the abdomen at the level of umbilicus. Histologic analysis of pancreas showed diffuse interstitial and peripancreatic neutrophilic infiltrate with areas of fat necrosis indicating AP. A section of the skin lesion demonstrated lobular fat necrosis with lipid-laden macrophages, calcification, organizing hemorrhage, fibrosis, and clusters of degenerating inflammatory cells consistent with pancreatic panniculitis (PP). The cause of death was acute myocardial infarction due to coronary artery thrombosis. Although pancreatic enzymes were elevated (amylase: 180 U/L; lipase: 220 U/L) abdominal computed tomography showed unremarkable pancreas. Neither AP nor PP was diagnosed before or during his hospital admission. Critically ill patients are known to be at risk for AP due to factors such as ischemia and drugs. It can be difficult to detect because of possible non-specific enzyme elevation and trouble gathering history regarding abdominal pain. Clinicians should be aware that PP can be the first manifestation of AP and its recognition can render the diagnosis earlier.