Case Report
Open Access
Lipogranulomatosis Subcutanea (Rothmann-Makai)
Wollina U1*, Gaber B1, Schonlebe J2
1Department of Dermatology and Allergology
2Institute of Pathology "Georg Schmorl", Academic Teaching Hospital Dresden-Friedrichstadt, Städtisches Klinikum, Dresden
2Institute of Pathology "Georg Schmorl", Academic Teaching Hospital Dresden-Friedrichstadt, Städtisches Klinikum, Dresden
*Corresponding author: Prof. Dr. U. Wollina, Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt,
Friedrichstrasse 41, 01067 Dresden, Germany E-mail:
@
Received: April 17, 2016; Accepted: April 24, 2016; Published: April 30, 2016
Citation: Wollina U, Gaber B, Schonlebe J (2016) Lipogranulomatosis Subcutanea (Rothmann-Makai). Clin Res Dermatol Open Access
3(3): 1-2. DOI: http://dx.doi.org/10.15226/2378-1726/3/3/00129
Abstract
Lipogranulomatosis subcutaneous (Rothmann-Makai) is a
rare localized non-infectious panniculitis of unknown etiology. We
report on a 70-year-old female patient, who developed several livid
subcutaneous nodules. Under the diagnosis of abscess formation a
surgical incision was performed in an outwards clinic. This resulted
in a suppurating lesion. Later the patient was referred to our
department since antibiosis was not helpful. We took a deep biopsy.
Histologic investigation demonstrated a predominant epitheloid-cell
granulomatous panniculitis. The combination of clinical findings,
absence of systemic symptoms and histology confirmed the diagnosis
of lipogranulomatosis subcutanea. The disease is an important
differential diagnosis to infectious panniculitis.
Keywords: Panniculitis; Lipogranulomatosis subcutanea; Granulomatous disorders; Treatment
Keywords: Panniculitis; Lipogranulomatosis subcutanea; Granulomatous disorders; Treatment
Case Report
A 70-year-old female patient presented with a 10 week
history of subcutaneous nodules on trunk and extremities.
She had no systemic symptoms, no pain, fever or malaise. She
reported that several nodules were incised (breast and arm) by
a surgeon. She was treated orally with cefuroxim 500 mg twice
daily and metronidazol 400 mg twice daily for five days without
any improvement. In the last five months the patient had lost 11
kg body weight due to diet.
Her medical history was positive for arterial hypertension, nephrolithiasis, and coxarthrosis. About 25 years ago her uterus was removed because of cervical spotting.
On examination we observed multiple painless subcutaneous nodules on her back, right breast, left arm and shoulder and left thigh. These nodules were initially skin-colored, later bluish with some telangiectasias and skin atrophy (Figure1).
Her medical history was positive for arterial hypertension, nephrolithiasis, and coxarthrosis. About 25 years ago her uterus was removed because of cervical spotting.
On examination we observed multiple painless subcutaneous nodules on her back, right breast, left arm and shoulder and left thigh. These nodules were initially skin-colored, later bluish with some telangiectasias and skin atrophy (Figure1).
Histology
We took two biopsies from the shoulder and the back. Tissue
was stained with hematoxylinin-eosin, periodic acid Schiff's
reaction, pan-cytokeratin, and CD68. In both biopsies a dominant
epitheloid cell, granulomatous panniculitis was described. The
lesions were partially necrotic and absceding. There was no hint
for actinomycosis (Figure 2).
Laboratory investigation
Antinuclear antibodies 1:80; Borrelia-IgM-westernblot
negative. Angiotensin-converting enzyme decreased with 5.8
U/l (normal range: 20-70 U/l). Alpha -1-antitrypsin and syphilis
serology normal or negative.
Microbiological swabs were taken from the right breast wound and the right upper arm. Bacterial cultures remained sterile. No yeasts were detected.
Microbiological swabs were taken from the right breast wound and the right upper arm. Bacterial cultures remained sterile. No yeasts were detected.
Imaging techniques
Computerized tomography of the trunk was unremarkable.
Treatment and course
The persistent wounds after incisions were treated topically
by sore flushing and framycetin/ lidocaine/ trypsin cones
(Leukase N, Merck).
Figure 1:Presentation of Lipogranulomatisis subcutanea. Left side:
Bluish colored older lesion. Right side: Earlier slightly erythematous
nodule..
Figure 2:Histology of lipogranulomatosis subcutanea. Left side: Hematoxylinin-
eosin stain (x2). Right side: Immunoperoxidase stain for CD68
(x2).
Oral treatment with non-steroidal ibuprofen, short course of
prednisolone (80 mg/d) tapered down, and pantoprazole was
initiated with rapid improvement.
Discussion
Lipogranulomatosis subcutanea (Rothmann-Makai) is a rare
idiopathic chronic panniculitis without systemic symptoms.
There is a broad range of differential diagnoses such as
erythema induratum Bazin, gummata, nodular vasculitis, lipoma,
panniculitis nodularis nonsuppurativa febrilis et recividans,
erythema nodosum, or abscess formation. The disease can
persist for months to years. The disease has been considered
an afebrile variant of panniculitis nodularis nonsuppurativa
febrilis et recidivans [1] or a subtype of Weber-Christian disease
withour internal manifestations [2]. Due to its rareness there is no standardized treatment. Oral corticosteroids, tetracylines and
clofazimine have been used in individual patients with success
[2, 3].
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