Track: Case Reports

Abstract:

A 59-year-old man with Grave’s disease status post thyroidectomy presented with one-year history of worsening left hip pain and firmness. Cutaneous examination revealed a dyspigmented bound-down atrophic plaque with bandlike induration extending across the left lateral hip. Left hip contrast-enhanced computed tomography (CT) showed subcuticular stranding involving superficial fascia and suggested sigmoid wall thickening. CT abdomen/pelvis with contrast confirmed diffuse sigmoid colon wall thickening and pericolonic stranding. Left hip incisional skin biopsy demonstrated lobular lymphocytic panniculitis with plasma cells, lymphocytic vasculitis, and hyalinized fat necrosis. Labs showed positive ANA (1:1280) and anti-dsDNA antibodies (12 IU/mL); additional extractable nuclear antigens were negative. Colonoscopy revealed pale sigmoid mucosa and marked tortuosity from rectum to transverse colon. Abdominal CT angiogram was negative for large vessel ischemia, yet demonstrated non-specific small vessel findings. Clinical correlation supported colonic ischemia. Additional labs revealed positive lupus anticoagulant, anti-cardiolipin, and anti-B2GPI antibodies. Together, findings rendered diagnoses of lupus panniculitis, systemic lupus erythematosus (SLE), anti-phospholipid syndrome, and sigmoid ischemic colitis. Treatment included: daily azathioprine 100mg PO, prednisone 40mg PO, aspirin 81mg PO; hydroxychloroquine 200mg PO BID; and coumadin (INR 2-3). Cutaneous induration partially improved within three weeks and flared after prednisone tapering; colitis symptoms fluctuated. Close monitoring on a slowed corticosteroid taper is ongoing. Lupus panniculitis is an uncommon form of cutaneous lupus; clinicopathologic correlation is paramount in securing a diagnosis. A minority of patients with lupus panniculitis will develop SLE; male sex and lower extremity location confer greater risk. Ischemic colitis is a rare, potentially life-threatening association.

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Woon Chow