DermNet provides Google Translate, a free machine translation service. Note that this may not provide an exact translation in all languages

Translate

Infective panniculitis

Author: Dr Tom Moodie, Dermatology Registrar, Waikato Hospital, Hamilton, New Zealand, 2013. DermNet NZ Revision September 2021


Infective panniculitis — codes and concepts
open

What is infective panniculitis?

Panniculitis of the skin is inflammation of the subcutaneous fat. It has many causes. An infective cause is more likely in those with immunodeficiency (a weakened immune system).

Immunodeficiency may be due to disease, such as infection with human immunodeficiency virus (HIV), or drug-induced immunosuppression (eg, prescribed after organ transplantation). Immunodeficiency may lead to infection with unusual organisms in unusual sites, including the subcutaneous fat.

Infective panniculitis

How does infective panniculitis present?

Infective panniculitis, in general, has no specific features. The clinical presentation depends on:

  • The type of organism
  • Its virulence (how harmful it is)
  • The route of inoculation
  • The immune state of the individual.

How is the diagnosis of infective panniculitis made?

Whilst history is important, the diagnosis usually requires microbiological and histological confirmation. On biopsy, most infectious panniculitis causes a lobular pattern of inflammation. A lobular pattern is nonspecific although there are sometimes clues that an organism is responsible. Cultures and special stains are required to distinguish these.

Bacterial causes of panniculitis

Common bacteria that cause panniculitis include:

Bacterial panniculitis can appear in immunocompetent as well as immunosuppressed individuals. It can develop as a result of direct inoculation or from seeding from systemic infection.

The classical histopathological appearance is a lobular or mixed lobular/septal suppurative panniculitis with heavy infiltrate of neutrophils.

The choice of antibiotic treatment depends on the specific bacteria identifed. If the microorganism is unknown, a broad-spectrum antibiotic such as amoxicillin-clavulanic acid is often chosen.

Mycobacterial panniculitis

Mycobacteria have a wide range of skin manifestations and panniculitis is uncommon. Most mycobacterial panniculitis is due to atypical mycobacteria including:

  • Mycobacterium chelonae
  • Mycobacterium fortuitum
  • Mycobacterium abscessus
  • Mycobacterium avium-intracellulare complex
  • Mycobacterium marinum
  • Mycobacterium leprae (leprosy, rare)
  • Mycobacterium ulcerans

Mycobacterial panniculitis is most frequently seen in immunocompromised individuals spreading through the bloodstream to present as widespread skin lesions. Trauma is the usual means of inoculation in individuals with a normal immune system and results in a single lesion.

Histology demonstrates lobular panniculitis, sometimes with granuloma formation. Zeihl-Neelson, auramine-rhodaine or Fite-Faraco stains are specialised mycobacterial stains that help highlight the organism. Cultures are more sensitive and allow for accurate identification of the mycobacterial species but can take many weeks. DNA probes and DNA PCR are quick ways of species identification.

Treatment regimes are specific to the species of mycobacteria. Treatment is usually continued for 6–12 months or at least 6–8 weeks after clinical resolution.

Treatment of cutaneous non-tuberculous mycobacterial infection
Micro-organism First Line Other treatment options
M. chelonae Clarithromycin + ciprofloxacin/doxycycline Surgical debridement
Dual antimicrobial therapy
M. fortuitum Amikacin + ciprofloxacin/doxycycline Surgical debridement
Dual antimicrobial therapy
M. abscessus Clarithromycin + amikacin/cefoxitin Surgical debridement/excision
M. marinum Ethambutol + rifampicin or doxycycline Surgical debridement
M. avium-intracellulare Ethambutol + clarithromycin + rifampicin Surgical excision

Fungal panniculitis

Fungal panniculitis can be separated into disseminated disease or classical subcutaneous mycosis.

  • A disseminated fungal infection affects very unwell immunocompromised individuals, who present with multiple inflamed subcutaneous nodules.
  • Classical subcutaneous mycosis develops in healthy individuals as a single nodule on the lower leg and then becomes an ulcer or abscess that does not respond to antibiotics.

Biopsyfungal culture and specific histology stains (silver-impregnated procedure and periodic acid-Schiff) are required to make the diagnosis.

Treatment of fungal panniculitis depends on the identification of the organism.

  • Disseminated fungal infections carry high mortality and require a long duration of antifungal treatment unless the immune system is reconstituted.
  • Classical subcutaneous mycosis is extremely difficult to cure and a long duration of antifungal treatment is required often preceded by complete surgical excision.
Features of deep fungal infections
  Disseminated fungal disease Classical subcutaneous mycosis
Causative organisms Candida spp, Aspergillus spp, Fusarium spp, Histoplasma capsulatum Sporotrichosis (Sporothrix schenckii), eumycetoma (Madurella mycetomatis), chromoblastomycosis (Phialophora verrucosaFonsecaea pedrosoi and F. compacta), zygomycosis (Entomophthorales)  
Patient characteristics Immunosuppressed individuals A healthy individual directly inoculated by soil, plant, or wood
Clinical manifestations Multiple inflammatory subcutaneous lesions
Individual very unwell
Single slowly growing subcutaneous nodule 
Can discharge pus and invade deep tissues
Histology Lobular panniculitis without vasculitis Lobular panniculitis without vasculitis
Occasionally, suppurative granuloma
Management Therapy may include itraconazole or amphotericin B (for months) 
Surgical excision may be needed for some lesions

Surgical excision
Itraconazole (months)

 

Viral panniculitis

The medical literature about viral panniculitis is limited to a few case reports. Cytomegalovirus (CMV) has been reported to cause panniculitis in an immunocompromised patient.

 

See smartphone apps to check your skin.
[Sponsored content]

 

Related information

 

Bibliography

  • Delgado-Jimenez Y, Fraga J, García-Díez A. Infective panniculitis. Dermatol Clin. 2008;26(4):471-vi. doi:10.1016/j.det.2008.05.005 PubMed 
  • Morrison LK, Rapini R, Willison CB, Tyring S. Infection and panniculitis. Dermatol Ther. 2010;23(4):328-40. doi:10.1111/j.1529-8019.2010.01333.x PubMed 
  • Torrelo A, Hernández A. Panniculitis in children. Dermatol Clin. 2008;26(4):491-vii. doi:10.1016/j.det.2008.05.010 PubMed 

On DermNet NZ

Books about skin diseases

See the DermNet NZ bookstore.

Sign up to the newsletter