Necrolytic migratory ulceration
A 53-year-old unmarried woman presented to us with history of recurrent episodes of erythematous scaly plaques over face, trunk and extremities of 12-year duration. Since 1 year she noticed vesicles at the margins of such plaques on the lower limbs, which broke down to form erosions and painful ulcers. These ulcers extended peripherally with tendency to heal centrally forming arcuate and annular patterns. Some of the lesions on the leg and hands developed thick waxy scales. She had been treated earlier as a case of psoriasis with no relief. She gave history of diabetes mellitus, weight loss and chronic diarrhea for the past 1 year.\nExamination revealed multiple scaly erythematous plaques of size 1-15 cm over the face, trunk and extremities and multiple annular plaques with thick waxy scales on the thighs, legs, palms and periorbital area []. There were also multiple crusted plaques over the dorsum of both feet and ankles []. This later progressed to multiple arcuate and annular ulcers of size 3-7 cm with irregular borders, marginal vesiculopustules, sloping edges and floor covered with granulation tissue and hemorrhagic crusting over feet and legs []. Additional findings included pallor, angular chelitis and ichthyosis. We investigated the patient with a differential diagnosis of psoriasis, Reiter's disease, pyoderma gangrenosum and acral necrolytic erythema.\nInvestigations showed hemoglobin level of 9.5 gm/dl; total leucocyte count of 13,300 with a differential count of 82% polymorphs and 16% lymphocytes; ESR of 100 mm; low serum zinc and albumin levels; elevated blood sugar levels; and negative HIV, HBsAg, VDRL and HCV serology. Other biochemical parameters were normal. No organism could be isolated despite repeated cultures for bacteria, mycobacteria and fungi. Skin biopsies from the plaque and margin of ulcers showed psoriasiform hyperplasia of the epidermis with focal parakeratosis, dyskeratotic cells and upper epidermal pallor with hydropic degeneration of keratinocytes []. The histopathology was suggestive of the family of necrolytic erythemas, which includes glucagonoma syndrome. But CT scan of the abdomen failed to detect any pancreatic tumors at the time. Due to monetary constraint the patient refused serum glucagon estimation.\nDuring the 3-month hospital stay the patient failed to improve with antibiotics, vitamin supplementation, injection human insulin and general supportive measures. The presence of chronic psoriasiform skin lesions, histologically belonging to the family of necrolytic erythemas[] and coexistent diabetes, made us consider the possibility of undetected glucagonoma. So we treated the patient empirically with oral zinc sulphate 220 mg thrice daily, amino acid infusions and monthly injections of 20 mg octreotide acetate. The skin lesions improved and healed completely in 1 month with residual pigmentary changes and scarring []. On discontinuation of treatment the skin lesions recurred, but responded again to the same line of management. One year later a repeat CT scan showed multiple hypodense lesions in the tail of the pancreas. A diagnostic FNAC from the mass lesion was planned from department of gastroenterology. But prior to the procedure patient developed altered sensorium of one day for which she was readmitted in that department. But her condition progressively worsened and she expired the next day despite resuscitative measures.