Clinical pictures

Abstract

Two cases of panniculus morbidus are presented.A 35-year-old man referred in 1994, with a 'double apron' with recurrent cellulitis. The patient was unable to leave his house alone, and cancelled several offers of ambulance transport to hospital. The patient was seen on a domiciliary visit. Demobbed from the army 10 years previously he had steadily gained weight, and 9 months before being seen described his abdomen 'dropping'. He was able to stand, but unable to walk unaided because his legs were splayed outwards to accommodate the swelling (Fig. 1). The swelling measured 89 × 50 cm, showed peau d'orange skin and was leaking serous fluid. A barium followthrough examination showed loops of small bowel within the mass. The patient had an estimated weight of approximately 250 kg. He had normal biochemistry. He was assessed by a consultant plastic surgeon and general surgeon, and by a lymphoedema specialist, but they concluded surgery would pose unacceptable risks. Repeated efforts to help him lose weight by diet (visits from community dietitians), and pharmacotherapy were made over a 3-year period, but the patient refused offers of in-patient admission for supervised weight loss. He died in 1998 at home -presumed from septicaemia and pulmonary embolus. Case 2A 59-year-old man was referred in 1991 to the obesity clinic from the respiratory clinic where he had been seen with a diagnosis of obstructive sleep apnoea. He weighed 222.5 kg, body mass index 77 kg m -2 . He was hypertensive and had angina but was felt to be too heavy for angiography. He was treated with a very-low-energy diet and reduced his weight by 22 kg over 6 months, but then regained this despite treatment with then available dexfenfluramine. He re-presented in December 1992 weighing 204 kg, having developed a swelling between his legs (Fig. 2). With a further period of supervised weight loss he reduced his weight to 170 kg by 1994, but then lapsed from follow-up and died of a presumed cardiac arrest in 1995.Lipo/lymphoedema of the legs is well described in obesity (1,2). Abdominal wall panniculus or pannus may also occur in severely obese individuals and has been termed panniculus morbidus (3) or elephantiasis nostras verrucosa (4) and causes severe problems with hygiene, immobility and chronic infection. It may be mistaken or misdiagnosed as malignancy (5,6). A previous report of a small series found that non-surgical management of the infected panniculus failed, and surgical approaches with resection clinical obesity