PMC5803941_01
(a) Multiple erythematous, round to oval, scaly lesions with distinct borders scattered mostly over the trunk (arrows); (b) Skin biopsy showing focal keratosis, parakeratosis and acanthosis with upper papillary dermal fibrosis with perivascular lymphocytic infiltrates (Hematoxylin and Eosin stain, x10); (c) Spongiotic changes and neutrophilic exocytosis, consistent with parapsoriasis with focal spongiotic dermopathy (Hematoxylin and Eosin stain x40)
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F1
General skin examination revealed multiple erythematous, round-to-oval, scaly lesions with distinct borders scattered mostly over the trunk [Figure 1a, arrow] and upper chest that were provisionally thought to be SPP, cutaneous T cell lymphoma, or tinea incognito. The dermatologist ordered a skin biopsy which revealed, focal keratosis, parakeratosis, and acanthosis with upper papillary dermal fibrosis with perivascular lymphocytic infiltrates [Figure 1b], along with few areas showing spongiotic changes and neutrophilic exocytosis, consistent with PP with focal spongiotic dermopathy [Figure 1c].
(a) Contrast CT imaging of abdomen showing bilateral intrahepatic biliary radicle dilatation (black arrow); (b) Soft tissue mass at the distal end of CBD and extending into the distal pancreatic duct (white arrow); (c) MRCP showing soft tissue mass at the lower end of CBD and distal pancreatic duct showing duct cut off signs (white circle)
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F2
A contrast-enhanced computed tomography imaging of the abdomen revealed bilateral intrahepatic biliary radicle dilatation [Figure 2a, black arrow], cystic dilatation of the branches of pancreatic duct near the head and uncinate process [Figure 2b, white arrow], with a soft tissue mass at the distal end of the common bile duct (CBD) and extending into the distal pancreatic duct causing dilatation of both ducts, which was confirmed by a magnetic resonance cholangiopancreatogram (MRCP) [Figure 2c, white circle], as well as a normal appearing liver and absence of lymphadenopathy or ascites.
(a) Pancreatic histology showing dilated main pancreatic duct with intermediate grade intraductal papillary mucinous neoplasm (IPMN) arranged in papillae, lined by pancreaticobiliary type epithelium (arrows, Hematoxylin and Eosin stain x20); (b) Focal mucinous appearance with lining cells showing focal crowding and stratification (arrows, Hematoxylin and Eosin stain, x40); (c) Occasional foci showing areas of microinvasion (arrow, Hematoxylin and Eosin stain, x40) and (d) Surrounding stroma showing mild inflammatory infiltrates (Hematoxylin and Eosin stain, x40)
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F3
Sections from the pancreas showed dilated main pancreatic duct showing intermediate-grade IPMN arranged in papillae, lined by pancreaticobiliary type epithelium focally showing mucinous appearance with lining cells showing focal crowding, and stratification [Figure 3a and b, arrows]. Occasional foci showed areas of microinvasion [Figure 3c, arrow] and surrounding stroma showing mild inflammatory infiltrates [Figure 3d].
Post Whipples surgery, the skin lesions resolved completely
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F4
One month after the surgery on follow-up, the patient is doing well, with complete resolution of the skin lesions [Figure 4] and increased appetite and weight gain.