| Author | Affiliation |
|---|---|
| Zachary S. Pacheco, MD | University of Alabama Birmingham Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama |
| Grace Johnson, MD | University of Alabama Birmingham Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama |
| Erin F. Shufflebarger, MD | University of Alabama Birmingham Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama |
ABSTRACT
Case presentation
We describe the case of a 38-year-old female patient with a history of lupus presenting with atraumatic abdominal pain and ecchymosis. The ultimate diagnosis of abdominal lupus erythematous panniculitis was determined based on physical exam and imaging findings.
Discussion
Lupus erythematous panniculitis is a rare diagnosis, but consideration is important as early recognition and treatment is important to reduce pain and lessen the possibility of irreversible disfigurement and unnecessary costs to affected patients.
CASE PRESENTATION
A 38-year-old female with a history of cutaneous lupus erythematosus on hydroxychloroquine presented to the emergency department (ED) with months of abdominal pain and two weeks of abdominal ecchymosis with underlying palpable nodules. She endorsed nausea without emesis, small-volume bowel movements, and shortness of breath secondary to pain. She denied similar previous episodes of this bruising or pain. However, the patient reported that her mother also had lupus with similar symptoms. Her abdominal exam was notable for generalized tenderness, diffusely scattered ecchymosis with palpable subcutaneous nodules (Image 1). Laboratory findings were unremarkable. Abdominal computed tomography was performed (Image 2).
The patient’s exam and imaging findings led to the diagnosis of lupus erythematous panniculitis (LEP) of the abdomen. After this diagnosis, she was discharged with a short course of steroids. At follow-up with her primary care physician weeks later, abdominal nodules were noted to be smaller in size and no longer tender.
DISCUSSION
This case describes a rare ED diagnosis of abdominal LEP. This condition is a rare variant of systemic lupus erythematosus, occurring in approximately 2% of patients with this condition; however, it can also be seen in association with discoid lupus erythematosus or in isolation.2 Most lesions have been described as affecting the proximal extremities, face, and back of middle-aged females with a prior diagnosis of lupus.2 In patients with history and clinical exam suggestive of LEP, imaging including ultrasound, computed tomography, or magnetic resonance imaging can be used to evaluate for underlying abscess and for further characterization of the lesions.3 However, biopsy and histopathology are recommended for definitive diagnosis.3
The diagnosis of LEP is often delayed for greater than one year, which can lead to preventable complications such as calcification or atrophy. Treatment often requires two or more systemic therapies including first-line hydroxychloroquine; recurrence is common.4 It is important that emergency physicians be aware of this rare diagnosis and consider it when evaluating patients with relevant medical history, as timely diagnosis and treatment is important for pain reduction, irreversible disfigurement, and costs for affected patients.4
CPC-EM Capsule
What do we already know about this clinical entity?
Lupus erythematous panniculitis (LEP) is rare, with lesions typically affecting the proximal extremities, face, and back of middle-aged females with a prior lupus diagnosis.
What is the major impact of the image(s)?
In patients with history and clinical exam suggestive of LEP, imaging aids evaluation for underlying abscess and further characterization of the lesions.
How might this improve emergency medicine practice?
Timely diagnosis and treatment is important for reducing pain and avoiding irreversible disfigurement and costs for affected patients.
Footnotes
Section Editor: Joel Moll, MD
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
The authors attest that their institution requires neither Institutional Review Board approval for publication of this case report. Patient consent was obtained. Documentation on file.
Address for Correspondence: Erin F. Shufflebarger, MD, University of Alabama Birmingham Heersink School of Medicine, Department of Emergency Medicine, GSB Suite 203, 521 19th Street South, Birmingham, AL 35233. Email: erinshufflebarger@uabmc.edu. 7:200 – 201
Submission history: Revision received March 26, 2023; Submitted June 6, 2023; Accepted June 5, 2023
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
REFERENCES
1. Diaz-Jouanen E, DeHoratius RJ, Alarcon-Segovia D, et al. Systemic lupus erythematosus presenting as panniculitis (lupus profundus). Ann Intern Med. 1975;82(3):376-9.
2. Fraga J, García-Díez A. Lupus erythematosus panniculitis. Dermatol Clin. 2008;26(4):453-63.
3. Kimball H, Kimball D, Siroy A, et al. Novel diagnostic imaging features of facial lupus panniculitis: ultrasound, CT, and MR imaging with histopathology correlate. Clin Imaging. 2019;58:177-81.
4. Rangel LK, Villa-Ruiz C, Lo K, et al. Clinical characteristics of lupus erythematosus panniculitis/profundus: a retrospective review of 61 patients. JAMA Dermatol. 2020;156(11):1264-6.