Retroperitoneal Panniculitis Mimicking High Intestinal Obstruction in a Young Female: A Case Report

Abstract

This case report examines retroperitoneal panniculitis in a 20-year-old female. The patient was presented with a history of epigastric discomfort for five days, vomiting after meals, fever, and abdominal bloating. Clinical examination revealed intestinal obstruction. Laboratory workup revealed high leukocytosis, raised urea, liver enzyme abnormality, and deranged coagulation. Diagnostic evaluation, including histopathology, confirmed retroperitoneal panniculitis. Surgical excision was performed, and postoperative treatment with corticosteroids was initiated. This case underscores the importance of considering retroperitoneal panniculitis in the differential diagnosis of patients with acute abdomen and bowel obstruction.

INTRODUCTION

Retroperitoneal panniculitis is a rare etiology of chronic retroperitoneal adipose tissue inflammation.[1] First described by Jura in 1924 about mesenteric fat, retroperitoneal involvement has only been reported in a limited number of cases. The condition predominantly affects males, with a male-to-female ratio of approximately 1.8, and its occurrence increases with advancing age.[2] The specific cause of this lesion is still unknown.[3] The diagnostic evaluation is evoked by computed tomography and rarely confirmed by biopsies. Surgical resection is attempted for complicated cases. Herein, a case of retroperitoneal panniculitis was presented that mimicked high intestinal obstruction in a young Indian woman.

CASE PRESENTATION

A 20-year-old female developed acute onset of epigastric pain, vomiting after meals, fever, and abdominal distension and presented to the emergency department after five days of symptoms. There was no significant medical, surgical, or travel history. On examination, she was upset and febrile. Her vital signs were blood pressure 110/70 mmHg, heart rate 118 bpm, respiratory rate 52 breaths/min, and oxygen saturation 80% on nasal oxygen. Abdominal examination revealed marked tenderness in the right iliac fossa, distension, muscular guarding, and sluggish bowel sounds. A clinical suspicion of acute intestinal obstruction was raised.

Laboratory investigations showed marked leukocytosis (White blood cell 31,590/μL with 92% neutrophils), elevated serum urea (124.3 mg/dL), mildly raised liver enzymes, and abnormal coagulation profile (Prothrombin time 21.5 sec, International normalized ratio 1.65). Arterial blood gas revealed respiratory alkalosis with compensated metabolic acidosis. Serum amylase and lipase levels were within normal limits, and GeneXpert testing for tuberculosis was negative.

A contrast-enhanced abdominal computed tomography revealed hepatomegaly, mild caecal wall thickening with diffuse fat stranding in the right iliac fossa and pelvis, omental haziness, mild ascites, and subcentimetric mesenteric and iliac lymphadenopathy. Bilateral pleural effusions and subsegmental consolidation were also noted [Figure 1]. These findings suggested an infective etiology, possibly tubercular in nature.

Figure 1.

Abdominal computed tomography scans showing the characteristic features of mesenteric panniculitis

Due to ongoing symptoms and concern for intestinal obstruction, an emergency exploratory laparotomy was performed. Intraoperatively, mild ascites, an inflamed appendix with pus flakes and hemorrhagic changes, and sloughed adipose tissue in the right retroperitoneum were noted. The affected retroperitoneal fat was excised and irrigated with saline, followed by an appendectomy. Histopathology examination confirmed a diagnosis of retroperitoneal panniculitis.

Postoperatively, the patient demonstrated marked clinical improvement following the initiation of corticosteroid therapy, with normalization of inflammatory markers and complete resolution of symptoms. She was discharged in stable condition.

DISCUSSION

The exact cause and pathophysiology of retroperitoneal panniculitis remain unclear. Potential contributing factors suggested in the literature include infections, autoimmune disorders, malignancies, and prior abdominal surgeries.[4] In the case discussed, the condition was considered idiopathic due to its self-limiting nature. While asymptomatic, when symptoms do occur, they tend to be vague and nonspecific.[5] On physical examination, findings may include a palpable abdominal mass, tenderness, distension, muscular guarding, or ascites.[5,6] Laboratory investigations are generally nonspecific and offer limited diagnostic value.[6,7] However, with advancements in imaging, particularly computed tomography and magnetic resonance imaging, distinguishing retroperitoneal panniculitis from other retroperitoneal pathologies like lymphoma, liposarcoma, desmoid tumors, or metastatic disease has become more feasible.[8] Imaging typically reveals a heterogenous, high-density lesion within the retroperitoneal fat, sometimes with calcifications or a fibrous capsule, but usually without invasion of surrounding structures.[8,9]

In some cases, especially when symptoms persist or the disease is chronic, histopathological confirmation via biopsy is advised. This may involve computer tomography-guided laparoscopic techniques as less invasive alternatives to open surgery.[10] Most cases resolve spontaneously and follow a self-limiting course, with recurrences being exceedingly rare. In the present case, the patient experienced a paralytic ileus, which clinically resembled a high-grade intestinal obstruction. Other uncommon complications reported include ureteric obstruction, reactive pancreatitis, and ascites.[10] Management of retroperitoneal panniculitis is typically tailored to the individual. Persistent or symptomatic cases may benefit from immunosuppressive therapy, including corticosteroids, azathioprine, colchicine, thalidomide, or cyclophosphamide. Surgical intervention may be necessary when medical therapy is ineffective, or complications arise.[10]

CONCLUSION

Retroperitoneal panniculitis, though rare, should be considered in cases of unexplained retroperitoneal inflammation or bowel obstruction. Awareness among clinicians is dynamic, as early diagnosis can prevent unnecessary extensive surgery. Histological confirmation and corticosteroid therapy paly pivotal roles in the management.

Consent for publication

Informed consent was obtained from the patient.

Ethical approval

Ethical approval is not required at our institution for an anonymous case report.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.