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Author: Dr Tom Moodie, Dermatology Registrar, Waikato Hospital, Hamilton, New Zealand, 2013.
Immunodeficiency may be due to disease, such as infection with human immunodeficiency virus (HIV), or with the use of immune suppressive drugs (e.g. prescribed after organ transplantation). Immunodeficiency may lead to infection with unusual organisms and in unusual sites, including subcutaneous fat.
Infective panniculitis, in general, has no specific features. The clinical presentation depends on:
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.
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 depends on the bacteria. If the organism is unknown, broad-spectrum antibiotic such as amoxicillin-clavulanic acid is often chosen.
Mycobacteria have a wide range of skin manifestations and panniculitis is uncommon. Most mycobacterial panniculitis is due to non-tuberculous or atypical mycobacteria. They include:
Mycobacterial panniculitis is more frequently seen in immunocompromised individuals. It is usually the result of spread through the bloodstream, which results in widespread 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.
|Micro-organism||First Line||Other considerations|
|M. chelonae||Clarithromycin + ciprofloxacin/doxycycline||Surgical debridement
Dual antimicrobial therapy
|M. fortuitum||Amikacin + ciprofloxacin/doxycycline||Surgical debridement
Dual antimicrobial therapy
|M. absessus||Clarithromycin + amikacin/cefoxitin||Surgical debridement/excision|
|M. marinum||Ethambutol + rifampicin or doxycycline||Surgical debridement|
|M. avium-intracellulare||Ethambutol + clarithromycin + rifampicin||Surgical excision|
Fungal panniculitis can be separated into disseminated disease or classical subcutaneous mycosis.
Treatment of fungal panniculitis depends on the identification of the organism.
|Features of deep fungal infections|
|Disseminated fungal disease||Classical subcutaneous mycosis|
|Causative organisms||Candida spp, Aspergillus spp, Fusarium, Histoplasma.||Sporotrichosis (Sporothrix schenckii), eumycetoma (Madurella mycetomatis), chromoblastomycosis (Phialophora verrocossa, Fonsecaea pedrosi and F. compacta).|
|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
|Eumycetoma needs wide excision and ketoconazole (months)
Chromoblastomycosis and Sporotrichosis are treated with itraconazole or terbinafine (months).
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.
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