Cutaneous Manifestation of Pancreatic Panniculitis

Figure 1

Cutaneous manifestation of pancreatic panniculitis. Disseminated livid-erythematous, partially ulcerated nodules on the lower limbs. The symmetrical involvement of the legs is typical; less commonly, the trunk or arms are also affected. Individual lesions that are painful to the touch show discharge of a brownish, viscous and oily necrotic material.

A man aged around 65 presented with a 4-week history of progressive livid-erythematous, partially ulcerated nodules on the lower legs. Gastrointestinal symptoms were absent despite laboratory results showing markedly elevated lipase levels (8946 U/L), elevated CRP levels (167 mg/L), and leukocytosis (27/nL). Computed tomography revealed necrotizing pancreatitis. Histological analysis of a skin lesion confirmed the diagnosis of pancreatic panniculitis (PP). This is a lobular, necrotizing panniculitis, a rare cutaneous manifestation of pancreatic disease. From a pathophysiological perspective, it is assumed that pancreatic enzyme-mediated damage to the microcirculation leads to extravasation of lipase and subsequent fat necrosis. Since abdominal symptoms in the setting of PP are often delayed or completely absent (in approximately 50% of cases), misdiagnosis and treatment delays are common. This contributes to the high mortality rate of over 25%. In the present case, the patient died shortly after hospital admission. Conclusion: In the case of cutaneous, livid-erythematous nodules, a pancreatic etiology should be considered early on even in the absence of abdominal pain, and an appropriate diagnostic evaluation (lipase measurement, imaging) should be performed.

Figure 2

Histology of the skin lesion (H&E stain). Lobular necrosis of the subcutaneous fat (left). At higher magnification (right), numerous anucleated adipocytes (so-called ghost cells) with preserved round to polygonal cell contours and thin eosinophilic cell membranes are observed (arrows). Some of the ghost cells show basophilic, fine granular to homogeneous intracytoplasmic material indicating calcium soap formation (cell circled as an example). Granular calcium deposits (arrowheads) and infiltrates of neutrophilic granulocytes (*) are also visible.

Dr. med. Gregor J. Wilken, Prof. Dr. med. Frank Tacke, PD Dr. med. Christian Fischer, Charité-Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Campus Virchow Klinikum und Campus Charité Mitte, [e-mail]

Conflict of interest statement: The authors state that no conflict of interest exists.

Translated from the original German by Christine Rye.

Cite this as: Wilken GJ, Tacke F, Fischer C: Cutaneous manifestation of pancreatic panniculitis. Dtsch Arztebl Int 2026; 123: 319. DOI: 10.3238/arztebl.m2026.0008