case_images: PMC5803941_01
case_images: (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)
case_images: IDOJ-9-40-g001.jpg
case_images: PMC5803941_01_IDOJ-9-40-g001.jpg
case_images: F1
case_images: 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].
case_images: (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)
case_images: IDOJ-9-40-g002.jpg
case_images: PMC5803941_01_IDOJ-9-40-g002.jpg
case_images: F2
case_images: 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.
case_images: (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)
case_images: IDOJ-9-40-g003.jpg
case_images: PMC5803941_01_IDOJ-9-40-g003.jpg
case_images: F3
case_images: 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].
case_images: Post Whipples surgery, the skin lesions resolved completely
case_images: IDOJ-9-40-g004.jpg
case_images: PMC5803941_01_IDOJ-9-40-g004.jpg
case_images: F4
case_images: 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.