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CORRESPONDENCE
Year : 2023 | Volume
: 41
| Issue : 1 | Page : 56-57
Poststeroid panniculitis in an 11-month-old boy after rapid cessation of high-dose systemic corticosteroids
Chun-Sheng Chen1, Po-Yuan Wu2
1 Department of Dermatology, China Medical University Hospital, Taichung, Taiwan
2 Department of Dermatology, China Medical University Hospital; School of Medicine, China Medical University, Taichung, Taiwan
Correspondence Address:
Dr. Po-Yuan Wu
Department of Dermatology, China Medical University Hospital, No. 2, Yude Rd., North District, Taichung 404327
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ds.DS-D-22-00199
Dear Editor,
An 11-month-old boy was born at 38 2/7 weeks of gestational age without any peripartum complications with a body weight of 2710 g. No abnormalities were seen on prenatal examination. After birth, he was diagnosed with a double-outlet right ventricle, ventricular septal defect, and patent ductus arteriosus. Due to congestive heart failure, he underwent surgery including patent ductus arteriosus ligation and pulmonary artery banding. A complete atrioventricular block was diagnosed postoperatively, and a permanent pacemaker was placed. Scheduled cardiac catheterization was performed at 9 months of age, which was complicated by a postoperative chylothorax. He was admitted for thoracentesis indicated for chylothorax-related respiratory failure. Four days after, several skin rashes developed on both legs and dorsal feet, for which he consulted our service. Skin findings revealed several erythematous infiltrated plaques on both legs and dorsal feet [Figure 1]. Pathological examination of the right leg revealed lobular panniculitis with mixed lymphocytes, histiocytes, neutrophils, and needle-shaped crystals in a radial orientation [Figure 2]. Direct immunofluorescence showed no evidence of immunoglobulin (Ig) G, IgM, IgA, or C3 deposition. Laboratory examination revealed the following values: white blood cell count, 10,500 cells/μl (64.1% neutrophils, 16.9% lymphocyte, 7.9% monocyte, and 10% eosinophil); hemoglobin level, 14.1 g/dL; platelet count, 184,000 platelets/μl; and C-reactive protein, 1.58 mg/dL. On review of the patient history, systemic prednisolone was administrated for respiratory failure before the skin rash developed as follows: 2 mg/kg/day for 3 days, 1 mg/kg/day for 3 days, 0.5 mg/kg/day for 3 days, and then stopped. The skin rashes on both legs and dorsal feet developed 11 days after rapid cessation of high-dose systemic corticosteroids. Based on these findings, he was diagnosed with poststeroid panniculitis. The skin lesions spontaneously subsided 1 week without any treatment.
Figure 2: Histopathology shows (a) scanning view: lobular panniculitis with crystals in fat lobules. (b-d) High-power view: lobular panniculitis with infiltration of lymphocytes, histiocytes, and needle-shaped crystals (arrow) in a radial orientationPoststeroid panniculitis is a rare complication of high-dose systemic steroid therapy, usually occurring days to weeks after cessation of high-dose systemic steroids,[1] most often seen in children. Erythematous asymptomatic or tender nodules and plaques on the cheeks, arms, forearms, thighs, and legs were ever reported.[2]
Histologically, poststeroid panniculitis manifests as lobular panniculitis with lymphocytic, granulomatous infiltration, and needle-shaped crystals in a radial orientation.[3] Similar microscopic findings were also found in subcutaneous fat necrosis of the newborn and sclerema neonatorum.[4] Subcutaneous fat necrosis of the newborn is rarely seen in the newborn with a history of perinatal complications such as asphyxia, hypothermia, and meconium aspiration. Subcutaneous fat necrosis of the newborn presents as painless erythematous nodules and plaques on the back, buttocks, and thighs. Microscopically, subcutaneous fat necrosis of the newborn has a similar presentation to poststeroid panniculitis. Sclerema neonatorum presents as diffuse skin hardening in a sick, premature newborn. The mortality rate of sclerema neonatorum is high, and it has a similar microscopic appearance to poststeroid panniculitis with only sparse inflammation.[1]
Poststeroid panniculitis has a good prognosis; it resolves in weeks to months without scarring. Gradual tapering of systemic steroids can reduce the risk of poststeroid panniculitis.[5]
In conclusion, we reported a case of poststeroid panniculitis with typical clinical presentation and microscopic findings. The differential diagnosis of typical histologic patterns of lobular panniculitis with granulomatous infiltration and needle-shaped crystals includes subcutaneous fat necrosis of the newborn and sclerema neonatorum. Accurate diagnosis is based on morphology and clinical history.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient's guardian consent form. In the form, the legal guardian has given the consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
References
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