Diagnosis: Necrolytic migratory erythema (glucagonoma syndrome)
A 62-year-old male with a history of diabetes presented with migratory annular eroded plaques and significant weight loss over three months. Clinical findings included erythematous plaques with central crusting and peripheral scaling. This case illustrates the unique cutaneous manifestation associated with underlying metabolic disorders.
A 62-year-old male presented with a three-month history of migratory annular eroded plaques and notable weight loss. The patient had a background of poorly controlled diabetes mellitus. On examination, there were multiple erythematous plaques with central crusting and a characteristic peripheral scale, primarily located on the abdomen and extremities.Distribution: Predominantly on the abdomen and extremities.Lesion morphology: Eroded plaques with annular configuration.Associated symptoms: Pruritus and tenderness in the affected areas.Systemic signs: Significant weight loss and signs of protein deficiency.
The patient reported that the lesions began as small erythematous spots that gradually expanded and merged over weeks. He denied any recent travel or new medications, but noted an increase in fatigue and decreased appetite. His medical history included type 2 diabetes and hypertension, with no family history of similar skin conditions. He has been a lifelong smoker and consumes alcohol socially.Onset: Lesions started approximately three months prior.Triggers: No identifiable triggers; gradual worsening of symptoms.Prior treatments: Topical steroids provided minimal relief.Relevant history: Type 2 diabetes, poorly controlled; no significant family history.Social history: Smoker, moderate alcohol use.
Acute / First-Line ManagementSupportive care focusing on nutritional supplementation to address protein deficiency, including high-protein nutritional shakes.Consider octreotide (100-600 mcg subcutaneously three times daily) for symptomatic relief and to reduce glucagon levels.Topical steroids may be used to manage localized inflammation.Workup and Diagnostic ConfirmationSerum glucagon levels should be measured; levels >500 pg/mL are suggestive of glucagonoma.Obtain a CT scan of the abdomen to evaluate for pancreatic tumors.Consider skin biopsy to rule out other conditions if lesions are atypical.Long-Term ManagementReferral to an oncologist for potential surgical resection of the glucagon-secreting tumor.Regular follow-up to monitor nutritional status and manage diabetes.Long-term management may include octreotide therapy for symptom control.
Psoriasis: Characterized by well-defined plaques with silvery scales; less likely to have central erosion.Erythema multiforme: Presents with target lesions; typically associated with infections or medications.Stevens-Johnson syndrome: Severe mucocutaneous reaction often with systemic involvement; history of drug exposure is key.Cutaneous T-cell lymphoma: May present with plaques, but usually has a more indolent course and associated lymphadenopathy.Nutritional deficiency dermatitis: Can cause similar lesions but is typically associated with malnutrition signs and symptoms.Dermatitis herpetiformis: Associated with gluten sensitivity; lesions are usually vesicular and intensely pruritic.Vasculitis: Often presents with petechiae or ulcers rather than annular plaques; systemic symptoms may be present.Drug reactions: Can mimic skin lesions but typically have an identifiable exposure history.
High-Yield PearlsGlucagonoma syndrome: Characterized by necrolytic migratory erythema, often associated with weight loss and diabetes.Weight loss: Significant weight loss in the context of skin lesions should raise suspicion for an underlying malignancy.Serum glucagon: Measurement is critical for diagnosis; levels >500 pg/mL are suggestive of glucagonoma.Octreotide: Can be effective in managing symptoms and controlling glucagon levels.Multidisciplinary approach: Involves dermatology, oncology, and nutrition for comprehensive management.Recognizing the skin manifestations of systemic disease can facilitate early diagnosis and intervention.
Tags: necrolytic migratory erythema, glucagonoma