Itchy Hyperkeratotic Acral Plaque in a Patient With Chronic Calcific Pancreatitis

Abstract

Question: A woman in her 40s complained of itchy, thick plaque of 5 years duration on her left foot. She had had a history of chronic calcific pancreatitis for which she had undergone Roux-en-Y lateral pancreaticojejunostomy followed by the Frey procedure some years later. She recalled the presence of a rash on both feet during this period. Even though she was on pancreatic enzyme replacement, she complained of occasional claycolored stools. She was on topical steroids and oral antihistamines from multiple care providers for the cutaneous lesion with no significant improvement in her symptoms. On examination, we noticed hyperpigmented, thick keratotic plaque on her left hind foot near the sole margin (Figure A). Histopathology (Figure B; hematoxylin and eosin stain; original magnification Â10) revealed acanthosis, diffuse parakeratosis, and necrotic keratinocytes tracking the acrosyringium (Figure B, green arrows) in the epidermis with lymphocytic infiltrates in the dermis. Her serum zinc level was 34.68 mg/dL (reference range, 54-151 mg/dL). Viral markers including hepatitis C virus (HCV) were nonreactive. The rest of the routine blood investigations were within normal limits. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.