Benign symmetric lipomatosis in a Chinese man with bullous pemphigoid

A 70-year-old Chinese man with biopsy proven bullous pemphigoid was treated with oral prednisolone, 60 mg daily, azathioprine, 100 mg daily, and dapso ne, 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 d istributed symmetrically on the occiput, neck, shoulder girdle, upper trunk , proximal upper extremities, and supraclavicular fossae (Figs 1a,b). The d eposits on the neck gave a characteristic, peculiar, "horse-collar" appeara nce (Fig. 2). The legs and lower part of the trunk were spared. The overlyi ng epidermis was normal. The overall appearance was pseudo-athletic instead of Cushingoid. Multiple, mobile, shotty lesions were palpable along the ne ck, suspicious of cervical lymph nodes. The patient had been drinking alcoholic beverages for 28 years, with an ave rage 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 matu re adipose tissue only. Complete blood counts were normal. Liver function t est showed isolated elevation of gamma-glutamyl transferase of 220 U/L (nor mal, 9-62 U/L) and low serum albumin of 35 g/L (normal, 44-56 g/L). Hepatit is 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 splee n. Liver parenchymal echogenicity was slightly increased, compatible with f atty change. Chest roentgenogram was normal. A computed axial tomography (C AT) 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 be nign symmetric lipomatosis (BSL). At the time of reporting, bullous pemphig oid was well controlled with prednisolone, 15 mg daily, and BSL remained st atic.