International Journal of Rheumatic Diseases 2015
CORRESPONDENCE
Factitious lobular panniculitis presenting as recurrent breast ulcers Dear Editor, A 22-year-old woman presented with 6-month complaints of polyarthralgia, intermittent low grade fever and bilateral large recurrent breast ulcerations. The ulcers reportedly started as painful nodular swellings in the breasts followed by ulceration after a few days. She had visited a number of medical practitioners including surgeons, with no benefit. She denied having any other significant past or current history. The general and systemic examinations were largely unremarkable, including no evidence of arthritis. She had a superficial and deep ulcer on the right breast, and a superficial healing ulcer on left breast (Fig. 1). There were multiple scars of previous lesions, including sutures, on both breasts. There were no underlying palpable nodules or associated lymph node enlargements. We considered a differential diagnosis of lupus mastitis, fat necrosis, sarcoidosis, malignancy, vasculitis and Weber–Christian disease. Her investigations, including erythrocyte sedimentation rate (ESR), hematological
parameters, renal and liver function tests, were within normal limits. She tested negative for antinuclear (ANA), anti-neutrophil cytoplasmic (ANCA) and antiphospholipid (APLA) antibodies. Ulcer swab Gram stain was negative and cultures were sterile. The biopsy of her breast ulcer revealed neutrophil-rich mixed inflammatory infiltrate with damaged fat lobules suggestive of lobular panniculitis (Fig. 2). Mammography of breasts did not reveal any abnormalities. The patient was started on oral steroids. The ulcers were dressed daily and the larger ulcer was sutured. The patient’s ulcers started improving. However, during her ward stay, she developed a new lesion on her right breast overnight. As her lesions were healing, the development of a new ulcer was not anticipated, especially because no preceding breast nodule had been noted. Closer inspection of the ulcer revealed features suggestive of an incised wound, with superficial, hesitation cuts, multiple incisions within the ulcer and the ulcer margins were sharp and superficial at the edges. Further,
Figure 1 Superficial and deep ulcer on right breast (right), healing superficial ulcer on left breast (left), residual scars on both breasts.
© 2015 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
Correspondence
Figure 2 Neutrophil-rich mixed inflammatory infiltrate with damaged fat lobules – lobular panniculitis.
the fact that this young woman was lying comfortably in bed with little pain and little mental distress despite significant mutilation of her breast, added to our suspicion. The possibility of factitious self-inflicted breast ulcers was considered. The patient denied self-inflicted injury. A psychiatry consult of the patient revealed significant stressors, severe depression and history of sexual abuse in childhood. We could not find any particular instrument to cause such a lesion, but possibility they were caused her by her sharp, long nails, or a hair-pin was considered. The patient was later started on antidepressants, steroids were tapered, her nails were trimmed, all sharp objects were removed from her vicinity, her breasts were bandaged and she was placed under 24-h supervision. The ulcers gradually healed and there were no recurrences. She subsequently confessed to using her sharp edged hair pin to inflict trauma when she was alone. She continues to be followed with psychiatry and there have been no new lesions in a 1-year follow-up period.
recurrent lesions with unusual geometry, especially in accessible sites.2,3 Panniculitis is one of such possible skin lesions.2,4 Factitious panniculitis has been reported due to blunt trauma, pinching, self injection and cupping therapy.5,6 Despite our patient’s initial denial, diagnosis of factitious disorder in her was supported by multiple facts. She had a history of multiple consultations, her signs and symptoms did not fit a medical disease, her investigations were normal, recurrence of her lesions at a similar site, and appearance of an incision wound like a new lesion. No occurrence of a new lesion after initiation of appropriate measures and her underlying psychiatric history supported our diagnosis. It was subsequently confirmed by her confession. Factitious panniculitis appears as lobular panniculitis on histology with or without fat necrosis.6 In cases of injected material there may be vacuoles with Swiss cheese pattern in th edermis and subcutis and the material may be visible on polarization.6 Factitious disorders may be associated with personality disorders or severe psychiatric illness as seen in our patient.7 It is difficult to diagnose and manage such patients. Careful bandaging or fibreglass encasing of affected parts can be both preventive and diagnostic for factitious skin lesions, as was seen in this patient.8 Treating the underlying psychiatric illness is imperative for best outcomes. Management may be more difficult in severe and chronic variants of this disorder, so labelled under the umbrella term Munchausen syndrome.9 Thus, factitious disorders should be considered in any patient with unexplained signs and symptoms, so as to avoid unnecessary treatment and excessive wastage of medical resources. Nilesh NOLKHA1, Anupam WAKHLU1, Vini TANDON2 and Nagma BANSAL1 1
DISCUSSION The term factitious comes from the Latin word for “artificial”. Factitious disorders are mental disorders in which a person acts as if he or she is physically or mentally ill, but the fact is that he or she has consciously created their symptoms.1 Factitious disorder differs from malingering, which is a term that refers to faking illness for financial gain.1 Self-induced skin lesions should always be considered in patients who do not fit a medical disease, have
2
Department of Rheumatology, King George Medical University, and 2Digdarshika Pathology, Lucknow, Uttar Pradesh, India Correspondence: Senior Resident Nilesh Nolkha, email: [email protected]
REFERENCES 1 Elder WG, Bennett K (2011) Somatoform disorders, factitious disorder, & malingering. In: South-Paul JE, Matheny
International Journal of Rheumatic Diseases 2015
Correspondence
SC, Lewis EL (eds) Current Diagnosis & Treatment in Family Medicine, pp. 597–604. McGraw Hill, New York. 2 Tausche AK, H€ansel S, Tausche K, Unger S, Schr€ oder HE, Pietsch J (2004) Case number 31: nodular panniculitis as expression of Munchausen’s syndrome (panniculitis artefacta). Ann Rheum Dis 63, 1195–6. 3 Faida A, Khanfir Monia S, Amira H, Imed BG, Mounir L, Mohamed Habib H (2012) A rare cause of lobular panniculitis: Munchausen’s syndrome. Case Rep Med 2012, 486421. 4 Koo J, Lebwohl A (2001) Psycho dermatology: the mind and skin connection. Am Fam Physician 64, 1873–8.
International Journal of Rheumatic Diseases 2015
5 Moon SH, Han HH, Rhie JW (2011) Factitious panniculitis induced by cupping therapy. J Craniofac Surg 22, 2412–4. 6 Robinson-Bostom L (2007) Panniculitis. In: Grant-Kels JM (eds) Color Atlas of Dermatopathology (Dermatology: Clinical and Basic Science Series/32), pp. 153–4. CRC Press, Florida. 7 Folks DG, Warnock JK (2001) Psychocutaneous disorders. Curr Psychiatry Rep 3, 219–25. 8 Oh CC, McKenna DB, McLaren KM, Tidman MJ (2005) Factitious panniculitis masquerading as pyoderma gangrenosum. Clin Exp Dermatol 30, 253–5. 9 Robertson MM, Cervilla JA (1997) Munchausen’s syndrome. Br J Hosp Med 58, 308–12.
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CORRESPONDENCE
Factitious lobular panniculitis presenting as recurrent breast ulcers Dear Editor, A 22-year-old woman presented with 6-month complaints of polyarthralgia, intermittent low grade fever and bilateral large recurrent breast ulcerations. The ulcers reportedly started as painful nodular swellings in the breasts followed by ulceration after a few days. She had visited a number of medical practitioners including surgeons, with no benefit. She denied having any other significant past or current history. The general and systemic examinations were largely unremarkable, including no evidence of arthritis. She had a superficial and deep ulcer on the right breast, and a superficial healing ulcer on left breast (Fig. 1). There were multiple scars of previous lesions, including sutures, on both breasts. There were no underlying palpable nodules or associated lymph node enlargements. We considered a differential diagnosis of lupus mastitis, fat necrosis, sarcoidosis, malignancy, vasculitis and Weber–Christian disease. Her investigations, including erythrocyte sedimentation rate (ESR), hematological
parameters, renal and liver function tests, were within normal limits. She tested negative for antinuclear (ANA), anti-neutrophil cytoplasmic (ANCA) and antiphospholipid (APLA) antibodies. Ulcer swab Gram stain was negative and cultures were sterile. The biopsy of her breast ulcer revealed neutrophil-rich mixed inflammatory infiltrate with damaged fat lobules suggestive of lobular panniculitis (Fig. 2). Mammography of breasts did not reveal any abnormalities. The patient was started on oral steroids. The ulcers were dressed daily and the larger ulcer was sutured. The patient’s ulcers started improving. However, during her ward stay, she developed a new lesion on her right breast overnight. As her lesions were healing, the development of a new ulcer was not anticipated, especially because no preceding breast nodule had been noted. Closer inspection of the ulcer revealed features suggestive of an incised wound, with superficial, hesitation cuts, multiple incisions within the ulcer and the ulcer margins were sharp and superficial at the edges. Further,
Figure 1 Superficial and deep ulcer on right breast (right), healing superficial ulcer on left breast (left), residual scars on both breasts.
© 2015 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
Correspondence
Figure 2 Neutrophil-rich mixed inflammatory infiltrate with damaged fat lobules – lobular panniculitis.
the fact that this young woman was lying comfortably in bed with little pain and little mental distress despite significant mutilation of her breast, added to our suspicion. The possibility of factitious self-inflicted breast ulcers was considered. The patient denied self-inflicted injury. A psychiatry consult of the patient revealed significant stressors, severe depression and history of sexual abuse in childhood. We could not find any particular instrument to cause such a lesion, but possibility they were caused her by her sharp, long nails, or a hair-pin was considered. The patient was later started on antidepressants, steroids were tapered, her nails were trimmed, all sharp objects were removed from her vicinity, her breasts were bandaged and she was placed under 24-h supervision. The ulcers gradually healed and there were no recurrences. She subsequently confessed to using her sharp edged hair pin to inflict trauma when she was alone. She continues to be followed with psychiatry and there have been no new lesions in a 1-year follow-up period.
recurrent lesions with unusual geometry, especially in accessible sites.2,3 Panniculitis is one of such possible skin lesions.2,4 Factitious panniculitis has been reported due to blunt trauma, pinching, self injection and cupping therapy.5,6 Despite our patient’s initial denial, diagnosis of factitious disorder in her was supported by multiple facts. She had a history of multiple consultations, her signs and symptoms did not fit a medical disease, her investigations were normal, recurrence of her lesions at a similar site, and appearance of an incision wound like a new lesion. No occurrence of a new lesion after initiation of appropriate measures and her underlying psychiatric history supported our diagnosis. It was subsequently confirmed by her confession. Factitious panniculitis appears as lobular panniculitis on histology with or without fat necrosis.6 In cases of injected material there may be vacuoles with Swiss cheese pattern in th edermis and subcutis and the material may be visible on polarization.6 Factitious disorders may be associated with personality disorders or severe psychiatric illness as seen in our patient.7 It is difficult to diagnose and manage such patients. Careful bandaging or fibreglass encasing of affected parts can be both preventive and diagnostic for factitious skin lesions, as was seen in this patient.8 Treating the underlying psychiatric illness is imperative for best outcomes. Management may be more difficult in severe and chronic variants of this disorder, so labelled under the umbrella term Munchausen syndrome.9 Thus, factitious disorders should be considered in any patient with unexplained signs and symptoms, so as to avoid unnecessary treatment and excessive wastage of medical resources. Nilesh NOLKHA1, Anupam WAKHLU1, Vini TANDON2 and Nagma BANSAL1 1
DISCUSSION The term factitious comes from the Latin word for “artificial”. Factitious disorders are mental disorders in which a person acts as if he or she is physically or mentally ill, but the fact is that he or she has consciously created their symptoms.1 Factitious disorder differs from malingering, which is a term that refers to faking illness for financial gain.1 Self-induced skin lesions should always be considered in patients who do not fit a medical disease, have
2
Department of Rheumatology, King George Medical University, and 2Digdarshika Pathology, Lucknow, Uttar Pradesh, India Correspondence: Senior Resident Nilesh Nolkha, email: [email protected]
REFERENCES 1 Elder WG, Bennett K (2011) Somatoform disorders, factitious disorder, & malingering. In: South-Paul JE, Matheny
International Journal of Rheumatic Diseases 2015
Correspondence
SC, Lewis EL (eds) Current Diagnosis & Treatment in Family Medicine, pp. 597–604. McGraw Hill, New York. 2 Tausche AK, H€ansel S, Tausche K, Unger S, Schr€ oder HE, Pietsch J (2004) Case number 31: nodular panniculitis as expression of Munchausen’s syndrome (panniculitis artefacta). Ann Rheum Dis 63, 1195–6. 3 Faida A, Khanfir Monia S, Amira H, Imed BG, Mounir L, Mohamed Habib H (2012) A rare cause of lobular panniculitis: Munchausen’s syndrome. Case Rep Med 2012, 486421. 4 Koo J, Lebwohl A (2001) Psycho dermatology: the mind and skin connection. Am Fam Physician 64, 1873–8.
International Journal of Rheumatic Diseases 2015
5 Moon SH, Han HH, Rhie JW (2011) Factitious panniculitis induced by cupping therapy. J Craniofac Surg 22, 2412–4. 6 Robinson-Bostom L (2007) Panniculitis. In: Grant-Kels JM (eds) Color Atlas of Dermatopathology (Dermatology: Clinical and Basic Science Series/32), pp. 153–4. CRC Press, Florida. 7 Folks DG, Warnock JK (2001) Psychocutaneous disorders. Curr Psychiatry Rep 3, 219–25. 8 Oh CC, McKenna DB, McLaren KM, Tidman MJ (2005) Factitious panniculitis masquerading as pyoderma gangrenosum. Clin Exp Dermatol 30, 253–5. 9 Robertson MM, Cervilla JA (1997) Munchausen’s syndrome. Br J Hosp Med 58, 308–12.
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