Corticosteroid-Induced Multifocal and Extensive Lipomatosis: A Case Report

doi:10.4236/ojpathology.2011.11001

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Open Journal of Pathology, 2011, 1, 1-3

doi:10.4236/ojpathology.2011.11001 Published Online October 2011 (http://www.SciRP.org/journal/ojpathology)

Corticosteroid-Induced Multifocal and Extensive

Lipomatosis: A Case Report

Ilham Bouaddi1, Hanan Rkain1, Fadoua Allali1, Nazik Allali2, Najia Hajjaj-Hassouni1

1Department of Rheumatology B, El Ayachi Hospital, Rabat-Salé, Morocco; 2Department of Radiology, Avicenne Hospital, Rabat-Salé,

Morocco.

Email: [email protected]

Received September 10th, 2011; revised October 12th, 2011; accepted October 23rd, 2011.

ABSTRACT

Introduction: Corticostero id-induced lipoma tosis are uncommon situation. We report a case of an extensive lipomato-

sis in a rheumatoid arth ritis patient, who received a long term steroid therapy. Case report: A 49-year-old rheumatoid

arthritis woman, who received for two years a mean dose of 15 mg/ day of prednisone equivalent, was admitted to the

hospital for a six months history of progressive abdominal distension and dyspnea. Physical exam revealed typical

symptoms of Cushing’s syndrome and an important increase of abdominal volume. Lipomatosis diagnosis with mesen-

teric, mediastinal, retroperitoneal and epidural localizations, was rapidly confirmed by sonography and computed to-

mography (CT) exams. Management was based on corticosteroid reduction as well as use of hygiene and dietary meas-

ures. Therapeutic efficacy was noted on a clinical basis within one year. Discussion: lipomatosis occurs as a less

known complication of long-term steroid therapy. Its localizations are numerous. Epidura l and mediastinal lip omatosis

are more frequent than mesenteric or retroperitoneal ones. Most frequently asymptomatic, lipomatosis could sometimes

be revealed by false symptoms. Medical treatment including corticosteroid with drawal or reduction and calorie re-

striction, can lead to clinical improvement. Surgery is reseved in advanced forms with serious complications.

Keywords: Lipomatosis , Mesenteric, Retroperitoneal, Mediastinal, Epidural, Corticosteroids

1. Introduction

In rheumatoid arthritis (RA), oral corticosteroids are ef-

fective for the short term relief of symptoms. Their toxic-

ity requires that they are used only when necessary, at the

lowest dose possible and for the shortest duration of time.

Long-term use of corticosteroids can lead to several com-

plications. The Cushing’s syndrome is the best model

illustrating the adverse effects of corticosteroids. The

lipomatosis steroid-induced is less known and was recen-

tly described [1]. We report a case of extensive lipoma-

tosis in a rheumatoid arthritis patien t and discuss charac-

teristics of this pathology.

2. Case Report

A 49-year-old rheumatoid arthritis woman, who received

for two years a mean dose of 15 mg/day of prednisone

equivalent, was admitted to the hospital for a six months

history of progressive abdominal distension and dyspnea.

Physical exam revealed and overweight (Body mass in-

dex at 29), typical symptoms of Cushing’s syndrome and

an important increase of abdominal volume (Figure 1).

Biological exams showed no abnormalities. An ab-

dominopelvic and thoracic computed tomography (CT)

scan showed collections of fat with an attenuation of

–125 to –1 00 Hounsfield units. This d eposition of adipo -

se tissue was in mesenteric, mediastinal, retroperitoneal

and epidural sites (Figures 2 and 3). Extensive and mul-

tifocal lipomatosis diagnosis was retained. Since patient

was not under Disease-modifying antirheumatic drugs

(DMAR- Ds), RA treatment was adjusted permitting to

reduce progressively the daily dose of corticosteroids.

Hygiene and dietary measures were also given to patient

who was overweight. Within one year, therapeutic effi-

cacy was noted on a clinical basis with 10 cm decrease of

the umbilical perimeter.

3. Discussion

Lipomatosis represents a diffuse overgrowth of mature

adipose tissue. It can be associated with obesity, steroid

ingestion, or Cushing’s syndr ome or ma y be idiopat hic [1].

Lipomatosis usually occurs for glucocorticoids dosages

above 0.5 mg/kg/day of prednisone equivalent [1-3]. The

duration of treatment and cumulative dose seem to be the

Current Distortion Evaluation in Traction 4Q Constant Switching Frequency Converters

Figure 1: Photographs of the patient showing clinical signs of Cushing syndrome and the increase of abdominal volume.

Figure 2. Abdominal CT scan showing mesenteric and

retroperitoneal lipomatosis.

more important determinants [3]. Our patient wasn’t fol-

lowed by a rheumatologist and therefore wasn’t under

DMARDS. The lack of adequate treatment of RA leads

her to chronic use of corti cost e roi d at hi g h dose.

Even if is not completely elucidated, glucocorticoid-

Figure 3. Chest CT scan showing mediastinal lipomatosis.

induced lipomatosis could be explained by the develop-

ment of fatty deposits in brown adipose tissue by the

reduction (secondary to steroid therapy) of the lipolytic

activity dependent receptor beta-3-adrenergic [1].

The localizations of lipomatosis are numerous. Epidu-

ral and mediastinal lipomatosis are more frequent than

Corticosteroid-Induced Multifocal and Extensive Lipomatosis: A Case Report 3

mesenteric or retroperitoneal ones. Lipomatosis is usu-

ally asymptomatic nevertheless; many nonspecific

symptoms could reveal this pathology [4,8-10]. In our

patient persistent dyspnea was the principal symptom.

Diagnosis of “Corticosteroid-induced multifocal and

extensive lipomatosis” in our case was retained by Com-

puterized tomography. This imaging and magnetic reso-

nance imaging are the principals tools to identify the dif-

ferents localizations of lipomatosis [1,5].

Treatment of lipomatosis is essentially medical. It is

based on the reduction or discontinuation of corticoste-

roid therapy if possible and the prescription of a hypo-

caloric diet, with restriction for four weeks of fast-acting

carbohydrate [6,7]. This treatment helps to reduce the

hyperinsulinemia and promotes lipolysis in adipose tis-

sue [6,7]. A more rational approach and concerted effort

should be applied in situations of corticosteroids use to

minimize their adverse effects and to evict a lipomatosis

complication. Our patient had a good evolution after diet

and progressive reducing of glucocorticoids thanks to

DMARDS onset. Surgery is required for complicated or

rapidly evolving forms [1]. The risks of surgery are im-

portant in these patients; it should be discussed taking

into account the clinical symptoms, the location and ex-

tent [2].

4. Conclusions

The lipomatosis steroid-induced is probably an underesti-

mated entity because of the prevalence of asymptomatic

forms. This diagnosis should be discussed in the context

of long-term corticosteroid. The scanner and MRI are the

key diagnostic tests, esp ecially in the early stages. Medi-

cal treatment is the first line treatment. Surgery is reser-

ved for complicated shapes.

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