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Hong Kong[TAB]A 70‐year‐old Chinese man with biopsy proven bullous pemphigoid was treated with oral prednisolone, 60 mg daily, azathioprine, 100 mg daily, and dapsone, 100 mg daily. Changes were observed in his body build within 2 weeks of steroid treatment. Clinical examination showed multiple, firm, lobulated, fat‐feeling masses distributed symmetrically on the occiput, neck, shoulder girdle, upper trunk, proximal upper extremities, and supraclavicular fossae ( Fig. 1a,b). The deposits on the neck gave a characteristic, peculiar, “horse‐collar” appearance ( Fig. 2). The legs and lower part of the trunk were spared. The overlying epidermis was normal. The overall appearance was pseudo‐athletic instead of Cushingoid. Multiple, mobile, shotty lesions were palpable along the neck, suspicious of cervical lymph nodes. 1 Anterior (a) and posterior (b) views of the patient showing symmetric deposition of adipose tissue in the upper trunk, supraclavicular fossae, and proximal upper limbs and typical sparing of the distal extremities 2 A close‐up view of the fat deposits on the occiput showing the characteristic “Madelung’s neck” The patient had been drinking alcoholic beverages for 28 years, with an average daily intake of 4 fluid ounces. There was no history of liver disease or other systemic diseases. No family member had a similar problem. Excisional biopsy of the neck mass was performed to exclude cervical lymph node metastasis and tuberculosis lymphadenitis. The histology revealed mature adipose tissue only. Complete blood counts were normal. Liver function test showed isolated elevation of γ‐glutamyl transferase of 220 U/L (normal, 9–62 U/L) and low serum albumin of 35 g/L (normal, 44–56 g/L). Hepatitis B surface antigen was negative. These changes were secondary to chronic alcoholism. Fasting urate, blood sugar, and triglyceride were within normal limits. Fasting cholesterol was 6.3 mmol/L (normal, 4.1–6.2 mmol/L) which was slightly elevated. Ultrasonic examination of the abdomen showed a normal sized liver and spleen. Liver parenchymal echogenicity was slightly increased, compatible with fatty change. Chest roentgenogram was normal. A computed axial tomography (CAT) scan of the thorax and abdomen did not reveal any mass lesion or lymph node. The whole clinical picture and investigations supported the diagnosis of benign symmetric lipomatosis (BSL). At the time of reporting, bullous pemphigoid was well controlled with prednisolone, 15 mg daily, and BSL remained static. Discussion
Hong Kong[TAB]A 70‐year‐old Chinese man with biopsy proven bullous pemphigoid was treated with oral prednisolone, 60 mg daily, azathioprine, 100 mg daily, and dapsone, 100 mg daily. Changes were observed in his body build within 2 weeks of steroid treatment. Clinical examination showed multiple, firm, lobulated, fat‐feeling masses distributed symmetrically on the occiput, neck, shoulder girdle, upper trunk, proximal upper extremities, and supraclavicular fossae ( Fig. 1a,b). The deposits on the neck gave a characteristic, peculiar, “horse‐collar” appearance ( Fig. 2). The legs and lower part of the trunk were spared. The overlying epidermis was normal. The overall appearance was pseudo‐athletic instead of Cushingoid. Multiple, mobile, shotty lesions were palpable along the neck, suspicious of cervical lymph nodes. 1 Anterior (a) and posterior (b) views of the patient showing symmetric deposition of adipose tissue in the upper trunk, supraclavicular fossae, and proximal upper limbs and typical sparing of the distal extremities 2 A close‐up view of the fat deposits on the occiput showing the characteristic “Madelung’s neck” The patient had been drinking alcoholic beverages for 28 years, with an average daily intake of 4 fluid ounces. There was no history of liver disease or other systemic diseases. No family member had a similar problem. Excisional biopsy of the neck mass was performed to exclude cervical lymph node metastasis and tuberculosis lymphadenitis. The histology revealed mature adipose tissue only. Complete blood counts were normal. Liver function test showed isolated elevation of γ‐glutamyl transferase of 220 U/L (normal, 9–62 U/L) and low serum albumin of 35 g/L (normal, 44–56 g/L). Hepatitis B surface antigen was negative. These changes were secondary to chronic alcoholism. Fasting urate, blood sugar, and triglyceride were within normal limits. Fasting cholesterol was 6.3 mmol/L (normal, 4.1–6.2 mmol/L) which was slightly elevated. Ultrasonic examination of the abdomen showed a normal sized liver and spleen. Liver parenchymal echogenicity was slightly increased, compatible with fatty change. Chest roentgenogram was normal. A computed axial tomography (CAT) scan of the thorax and abdomen did not reveal any mass lesion or lymph node. The whole clinical picture and investigations supported the diagnosis of benign symmetric lipomatosis (BSL). At the time of reporting, bullous pemphigoid was well controlled with prednisolone, 15 mg daily, and BSL remained static. Discussion
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