Panniculitis: problems of differential diagnosis. Panniculitis-fibrotic inflammation of subcutaneous tissues, symptoms and treatment

Inflammation of the subcutaneous fatty tissue (SFA) is called panniculitis (translated from the Latin ending “IT” means inflammation). At the moment there is no unified classification of panniculitis, but they are combined according to etiological indications and microscopic examinations.

Types of inflammation of subcutaneous fat tissue

1. Panniculitis associated with changes in connective tissue septa directly between areas of subcutaneous fatty tissue, under the influence of the inflammatory process. This inflammation is called septal inflammation of the subcutaneous fatty tissue (from the Latin septum - septum).

2. Panniculitis associated with inflammatory changes in the subcutaneous tissue lobules. And in this case it will be lobular panniculitis (from the Latin lobules - lobule).

Under a microscope

With a microscopic examination, enlarging nodes can be detected in the subcutaneous fatty tissue, which in the future is not difficult to notice with the naked eye. Such nodes actively grow and reach sizes of 1 - 6 cm in diameter. They may be painless, but it is also possible to experience pain in the affected area. As a rule, such inflamed nodes in the pancreas are located mainly under the skin in various parts of the body (often have a symmetrical location), in the mammary gland, lower leg, thigh, and the buttock area can also be affected.

Cause

The cause of this disease is a metabolic disorder, in particular fat metabolism. In places where panniculitis appears, general signs of inflammation appear: redness, swelling, pain (but not always), increased temperature directly at the site of inflammation (local hyperthermia).

Symptoms

The inflammatory process will also affect the general condition of the patient, i.e. signs of intoxication (poor health, fever, loss of appetite, possible nausea and vomiting, muscle pain). There may be cases where several inflammatory nodes appear in one lesion, and the formation of adhesions between them is possible. Resolution of such nodes occurs depending on the body’s immune system, as well as the ability of subcutaneous fatty tissue and skin to regenerate (replacement of damaged areas with new tissue). Quite often, over the course of many years, periods of exacerbation of the disease and remission (attenuation) occur. You can do proper dressings at home as prescribed by a doctor to maintain regeneration processes. These can be ointments with solcoseryl or others recommended by the doctor specifically for you.

Outcome and consequence

Outcomes of panniculitis: in the first case, healing occurs within several weeks without the formation of skin defects, in the second case, healing can take up to a year. In the latter case, retraction of the skin in the area of inflammation and tissue atrophy may be observed. Another possible outcome is to open the node and isolate specific contents. As a rule, processes of necrosis and ulcer formation are observed. Since not only the epidermis, but the dermis is damaged, in this case a scar will necessarily form on the skin. The surgeon needs to carry out proper primary surgical treatment and, if possible, apply a cosmetic suture to reduce the scar.

Risk of calcification

It is also impossible to exclude the possibility of calcium being deposited in the inflamed nodes, and in such cases it will be called calcification. This disease is dangerous primarily because nodes can form in various places, including in internal organs (for example, the fatty capsule of the kidney). This may adversely affect the function of a particular organ. With laboratory research methods, in a general blood test, an increase in the ESR indicator will be observed, and the indicators of lymphocytes and leukocytes will be reduced.

For treatment, antibacterial (broad-spectrum antibiotics) and vitamin therapy, glucocorticoids, and local application of ointment to the affected areas are prescribed.

– a rare disease that is characterized by inflammation of the subcutaneous tissue of the omentum and retroperitoneal space. Diagnosis is difficult. Does not pose a danger to life.

The reasons are not fully known. Only numerous factors have been identified that can contribute to the onset of the pathological process. Among the possible causes of the development of mesenteric panniculitis, the following effects and situations are considered:

It is difficult, almost impossible, to predict the likelihood of developing mesenteric panniculitis, since the above-mentioned provoking factors can lead to other results. With a slightly higher frequency, this disease is registered in middle-aged men.

Symptoms

Clinical manifestations of mesenteric panniculitis are scanty and nonspecific. Often the patient does not feel any significant discomfort. In many cases, only systemic manifestations are observed, which force the patient to see a doctor and undergo examinations. Among the possible signs, the most likely ones are:

In some cases, a constant, long-term unmotivated temperature comes to the fore, which is briefly relieved by traditional antipyretics and then rises again. This is what becomes the main problem for the patient - a temperature not associated with anything specific, which changes the usual rhythm of life and reduces its quality.

Diagnostic methods

They are diverse and variable, since they are no longer aimed at diagnosing mesenteric panniculitis, but at excluding other infectious and non-infectious pathologies. Complex diagnostics uses:

The last 2 research methods reveal the formation of thickenings in places characteristic of mesenteric panniculitis (omentum, fatty tissue of the retroperitoneum) and an increase in certain groups of lymph nodes (mesenteric, mesenteric). Only in exceptional cases (suspicion of a malignant neoplasm) is a diagnostic laparotomy followed by suspicious lesions.

Treatment

It is divided into conservative and surgical. In most cases, the first treatment option is practiced.

Conservative therapy

The patient is not prescribed special therapeutic nutrition or activity restrictions. A diet is not required, since disturbances in the absorption and digestion of nutrients are rare. During periods of high temperature, dairy-vegetable dishes are recommended, which are easily absorbed by the body.

The physical activity regimen is limited only by the patient's condition. If the temperature is above 39 °C or more, accompanied by chills and severe weakness, there is no talk of any productive physical or mental activity.

Drug therapy is aimed at eliminating the suspected microbial agent and eliminating its pathological effect on the human body. The most commonly used:

The duration of therapy is selected individually. The main criterion for drug withdrawal is normalization of temperature and reduction in the size of the inflammation site according to the results of ultrasound and MRI.

Surgical therapy

It is used only in exceptional cases when it is impossible to differentiate a malignant neoplasm from mesenteric panniculitis. In such a situation, surgical intervention is performed to remove pathological formations.

Prognosis and possible complications

Mesenteric panniculitis does not pose a threat to the patient's life. Inflammatory changes (edema, hyperemia) in the adipose tissue of the omentum, mesentery and other organs rarely significantly disrupt the function of adjacent organs. Only mechanical compression is possible during a massive process.

Complications - thrombosis, suppuration - develop extremely rarely. Only in this case there is a threat to the patient’s life in the absence of adequate treatment.

Prevention

It has not been developed and is inappropriate, since the causes of the development of mesenteric panniculitis have not been precisely established.

A progressive lesion of subcutaneous fatty tissue of an inflammatory nature, leading to the destruction of fat cells and their replacement with connective tissue with the formation of nodes, plaques or infiltrates. In the visceral form of panniculitis, damage occurs to the fat cells of the liver, pancreas, kidneys, fatty tissue of the omentum or retroperitoneal region. Diagnosis of the disease is based on the clinical picture and histological examination data. Treatment of panniculitis depends on its form.

The infiltrative version of panniculitis occurs with the melting of nodes or their conglomerates. In this case, in the area of the node or plaque, usually of a bright red or burgundy hue, a fluctuation appears, typical of an abscess or phlegmon. However, when the nodes are opened, it is not pus that comes out of them, but an oily yellow mass. At the site of the opened node, a long-term non-healing ulceration forms.

A mixed version of panniculitis is rare and represents a transition from a nodular form to a plaque form, and then to an infiltrative one.

Changes in subcutaneous fatty tissue in the case of spontaneous panniculitis may not be accompanied by a violation of the patient’s general condition. But more often, at the onset of the disease, symptoms similar to those of acute infections (ARVI, influenza, measles, rubella, etc.) are observed: headache, general weakness, fever, arthralgia, muscle pain, nausea.

The visceral form of panniculitis is characterized by systemic damage to fat cells throughout the body with the development of pancreatitis, hepatitis, nephritis, and the formation of characteristic nodes in the retroperitoneal tissue and omentum.

In its course, panniculitis can be acute, subacute and recurrent, lasting from 2-3 weeks to several years. The acute form of panniculitis is characterized by a pronounced change in general condition with high fever, myalgia, joint pain, impaired renal and liver function. Despite the treatment, the patient's condition progressively worsens, occasionally there are short-term remissions, but within a year the disease ends in death.

The subacute course of panniculitis is smoother. It is typically characterized by a disturbance in the general condition, fever, changes in liver function tests, and resistance to treatment. The most favorable course of panniculitis is recurrent or chronic. At the same time, relapses of the disease are not severe, often without changes in general health, and alternate with long-term remissions.

Diagnosis of panniculitis

The dermatologist diagnoses panniculitis together with a rheumatologist, nephrologist and gastroenterologist. The patient is prescribed a biochemical test of blood and urine, liver tests, pancreatic enzyme tests, and the Rehberg test. Identification of nodes of visceral panniculitis is carried out using ultrasound of the abdominal organs, ultrasound of the kidneys. pancreas and liver ultrasound. Blood culture testing for sterility allows us to exclude the septic nature of the disease. To differentiate the infiltrative variant of panniculitis from an abscess, a bacteriological examination of the separated opened node is carried out.

An accurate diagnosis of panniculitis is established based on the results of a biopsy of the node. Histological examination reveals inflammatory infiltration, necrosis of fat cells and their replacement with connective tissue. Diagnosis of lupus panniculitis is based on data from immunological studies: determination of antinuclear factor, antibodies to ds-DNA, complement C3 and C4, antibodies to SS-A, etc.

Differential diagnosis of panniculitis is carried out with erythema nodosum, lipoma, oleogranuloma, insulin lipodystrophy in diabetes mellitus,

Panniculitis is an inflammatory lesion of the subcutaneous fatty tissue, which can ultimately lead to its complete destruction. Sometimes this pathology is also called fatty granuloma. It was first described in 1925 by Weber. According to statistics, panniculitis most often affects women aged 20 to 50 years.

What is panniculitis?

Panniculitis is characterized by the absence of specific symptoms, so it is often confused with other skin diseases. There is also no consensus among doctors about the reasons why this disease may occur.

According to statistics, in approximately 40-50% of cases, inflammation of fatty tissue occurs against the background of relative health. It can be provoked by pathogenic or opportunistic bacteria, viruses and even fungi that penetrate the adipose tissue through damaged skin.

The development of inflammation of adipose tissue is based on disturbances in one of the metabolic mechanisms in adipose tissue, namely lipid peroxidation, which can occur for various reasons.

Types of disease

Depending on whether the inflammation of the subcutaneous tissue appeared independently or occurred against the background of some other pathology, panniculitis can be primary (idiopathic) or secondary. The primary form of the disease is also called Weber-Christian panniculitis.

There is another classification of pathology. Depending on the nature of the changes that occur on the skin, it can be:

Nodular, in which single nodes, isolated from each other, ranging in size from several millimeters to a centimeter appear under the skin. The skin over them becomes burgundy and may swell.
Plaque, manifested by the formation of many single compactions, which can grow together into fairly large conglomerates. In severe cases, they can compress blood vessels and nerve endings, cause the development of edema, poor circulation and loss of sensitivity.
Infiltrative, in which panniculitis looks like an abscess or phlegmon. The only difference between them is that yellowish liquid accumulates inside the nodes, not pus. After opening the node, a poorly healing ulceration remains in its place.
Visceral, in which the manifestations on the skin are accompanied by damage to the internal organs. This happens due to the fact that the pathology affects the retroperitoneal tissue. Typically, this form affects the liver, pancreas and kidneys.

Regardless of the type, panniculitis can occur in an acute, most severe, or subacute form. Sometimes it can also take on a chronic course, in which exacerbations are usually milder and separated by long periods of remission.

Reasons

Primary inflammation of the subcutaneous adipose tissue can occur due to the penetration of infection into the subcutaneous adipose tissue. Its development can be triggered by injuries, even minor ones, burns or frostbite, as well as insect or animal bites. As for the secondary form of pathology, depending on the cause, panniculitis can be:

Immunological, that is, develop due to disorders in the immune system, for example, with systemic vasculitis or erythema nodosum.
Lupus, which occurs against the background of systemic lupus erythematosus.
Enzymatic, occurring against the background of developed pancreatitis due to the high activity of pancreatic enzymes.
Proliferative cellular, which is provoked by pathologies such as leukemia or lymphoma.
Artificial or medicinal, which develops due to the use of certain medications. An example of such a pathology is steroid panniculitis, which often develops in children after a course of corticosteroids.
Crystalline, occurring against the background of gout and renal failure which lead to the deposition of calcifications or urates in the subcutaneous tissue.
Genetic, developing due to a hereditary disease in which there is a deficiency of the enzyme 1-antitrypsin. Most often, it is this reason that causes the development of the visceral form of the disease.

With the exception of drug-induced panniculitis, which in most cases goes away on its own over time, all other forms of the disease require mandatory treatment. Only a doctor should prescribe it.

Symptoms

The main symptom of the disease is the growth of plaques under the skin or the appearance of single nodes. They are located mainly on the legs or arms, less often in the abdomen, chest or face. In addition, symptoms of the disease include:

Redness in the affected area, painful areas and local fever.
Small red dots, rashes, or blisters on the skin.
Signs of general intoxication of the body, such as weakness and pain in muscles and joints, headache and fever, especially when panniculitis is caused by viruses.

In addition to general symptoms, with the visceral form of pathology, signs of damage to various organs will also appear. If the liver suffers, then symptoms of hepatitis will appear; if the kidneys are affected, nephritis will appear; and in the case of the pancreas, pancreatitis will appear. In addition, with the visceral form, characteristic nodes will form on the omentum and in the retroperitoneal space.

If you notice warning signs on your skin, consult a doctor as soon as possible. A dermatologist, dermatovenerologist, infectious disease specialist, surgeon or therapist can help you in this case.

Treatment

Unfortunately, panniculitis is one of those pathologies that require long-term and complex treatment, especially if the patient did not consult a doctor in time and the diagnosis was made late. In acute form, the disease can last 2-3 weeks, in subacute or chronic form - up to several years. However, regardless of the form of the pathology, treatment will always be comprehensive.

In each case, the doctor selects an individual treatment regimen depending on the patient’s characteristics and the presence or absence of concomitant diseases.

In addition, for nodular and plaque forms of panniculitis, the regimen may include cytostatic drugs, such as Methotrexate or Azathioprine.

The most difficult to treat is the infiltrative form of panniculitis. In severe cases, even large doses of glucocorticosteroids and antibiotics do not help. Therefore, to treat this pathology, in some situations, doctors prescribe tumor necrosis factor (TNF) drugs.

In addition to the main drugs, the treatment regimen may also include auxiliary agents, for example, hepatoprotectors or antioxidants. Physiotherapy may also be prescribed: phonophoresis, magnetic therapy or ultrasound.

Possible complications and prevention

Since the exact mechanism of development of the disease is still unknown, there is no specific prevention of panniculitis as such. The exception is the secondary form, in which doctors advise not to allow an exacerbation of the primary pathology that provokes the development of panniculitis.

As for the prognosis and complications, first of all it will depend on the specific form of the disease and when the diagnosis was made and treatment began. Panniculitis, treatment of which is started in the early stages, goes away much faster and is less likely to cause complications.

The most unfavorable and severe course is the acute form of panniculitis, which can often be complicated by sepsis. Subacute and chronic forms, as a rule, in most cases resolve over time without complications.

Panniculitis is an inflammatory process expressed in damage to the subcutaneous fatty tissue. It leads to the replacement of adipose tissue with connective tissue, provokes the formation of nodes, infiltrates and plaques. According to experts, often with panniculitis there is damage to the fat cells of internal organs.

IMPORTANT: Panniculitis can occur in patients of any age, including children. According to statistics, women and men have the same susceptibility to this dermatological disease.

About half of all cases of the disease occur due to spontaneous panniculitis, which affects women 20-60 years old. Other cases of the disease refer to the secondary form of panniculitis, which occurs due to cold, certain medications and diseases. The basis of this disease is a violation of fat oxidation, but medical specialists still do not know the mechanism of panniculitis.

Classification of panniculitis

The primary, or spontaneous, form of panniculitis is called Weber-Christian panniculitis. It is distinguished by its random occurrence without the influence of any factors. The secondary form of panniculitis appears for many different reasons, which gave rise to its classification:

Immunological panniculitis. Appears against the background of systemic vasculitis. May appear in children as a variant of erythema nodosum
Lupus panniculitis, or lupus form. Occurs in the presence of an acute form of systemic lupus erythematosus. Symptoms of panniculitis are combined with symptoms that are characteristic of disoid lupus
Enzymatic panniculitis. Associated with the influence of pancreatic enzymes, the level of which increases in diseases such as pancreatitis
Proliferative cell panniculitis. It is a consequence of diseases such as histiocytosis, lymphoma, leukemia and others

Panniculitis on the palm

Cold panniculitis. This is a localized panniculitis that appears as a reaction to exposure to cold. Often manifests itself in the form of pinkish dense nodules that go away on their own after a couple of weeks
Steroid panniculitis. Occurs in children 7 days after taking corticosteroid drugs. Goes away on its own
Artificial panniculitis. Occurs after the administration of certain medications
Crystalline panniculitis. Develops in the case of gout or renal failure due to the deposition of urates and calcifications in the subcutaneous tissue, as well as the appearance of crystals after the administration of pentazocine and meneridine
Hereditary panniculitis. It is associated with a deficiency of α1-antitrypsin, a special substance that inhibits the activity of other harmful substances

Depending on the form of skin damage, experts distinguish the following forms of the disease:

Plaque panniculitis
Nodular panniculitis
Infiltrative panniculitis

Panniculitis on the legs

Disease statistics

Panniculitis should not be considered a widespread disease, but cases of this disease do occur. For example, in 2009 in England there were approximately 80 thousand cases of panniculitis development leading to the patient's hospitalization.

Panniculitis can occur in patients of any age, including children. According to statistics, women and men have the same susceptibility to this dermatological disease.

Over the past decade and a half in England, the incidence rates of this disease increased 3 times. Until now, the reason for this has not been clarified, but it may be associated with certain strains of bacteria that cause panniculitis, or a greater prevalence of risk factors for developing the disease. According to experts, the increase in cases of panniculitis may be caused by a combination of both reasons.

Identified risk factors for developing the disease include the following:

Weakened immunity. It can be caused by diabetes, HIV infection and other ailments. A weakened immune system may be a side effect of certain treatments, such as chemotherapy.
Lymphedema. This is a disorder in which swelling of the soft tissues is noted. May appear spontaneously or after intervention to remove certain types of tumors
Intravenous drug use

Symptoms of panniculitis

The main manifestation of spontaneous panniculitis is nodular formations, which are located at different depths in the subcutaneous fat. Most often they occur on the extremities, a little less often on the face, chest and abdomen. After these nodes are destroyed, small areas of atrophy of adipose tissue remain, looking like round areas of recessed skin.

Nodular panniculitis is characterized by the appearance of single nodes with a diameter of up to 5 centimeters. Usually the skin over the nodes changes color up to to bright pink.

Affected finger

In the case of plaque panniculitis, clusters of nodes occur that grow together into large areas of the lesion (conglomerates). The color of the skin over them varies from pink to burgundy-bluish. Sometimes these conglomerates spread to almost the entire tissue of the thigh, shoulder or lower leg, compressing the nerve and vascular bundles. This compression causes swelling and soreness and then leads to lymphostasis– disruption of lymph outflow from the limb.

With infiltrative panniculitis there is melting of nodes and conglomerates. Plaques and nodes usually have a characteristic burgundy or bright red hue, and in their area a fluctuation typical of an abscess appears. If the nodes are opened, then not pus will come out of them, but an oily yellowish mass, and an ulceration will form at the site of the opening, which does not heal for a long time.

The least common type of panniculitis is a mixed one, and it is usually a transitional form between different types of panniculitis.

Sometimes, in the case of spontaneous panniculitis, changes in fat tissue are not accompanied by deterioration of the patient's condition. However, most often there is weakness, headache, fever, nausea, muscle pain and other symptoms similar to manifestations of infections (influenza, ARVI, measles, etc.).

Depending on the course, panniculitis is divided into three types:

Acute panniculitis- it is characterized by a general deterioration in the patient’s condition, impaired liver and kidney function. Even despite treatment, the patient’s condition deteriorates greatly, the disease is interrupted by short remissions, but after a year, as a rule, death occurs
Subacute panniculitis– it flows more softly than sharp. It is characterized by fever and deterioration of general condition. Treatment in this case is very effective
Recurrent or chronic panniculitis– the most favorable form of the disease. Relapses of panniculitis are not too severe and are interrupted by very long remissions

Treatment of panniculitis

Panniculitis is treated depending on its course and form. Anti-inflammatory drugs and antioxidants help against nodular chronic panniculitis, and isolated formations are treated with glucocorticoids. Physiotherapy also has a significant effect.

IMPORTANT: The primary, or spontaneous, form of panniculitis is called Weber-Christian panniculitis. It is distinguished by its random occurrence without the influence of any factors.

For the treatment of plaque and infiltrative forms, as well as for subacute panniculitis, they are used cytostatics- drugs that prevent cell division and the spread of tumors - and glucocorticosteroids - substitutes for adrenal hormones, which are an anti-inflammatory agent.

Background forms of panniculitis are treated primarily by getting rid of the underlying disease.

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