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Paper text:
this disease may be considered a reactive process , often associated with a systemic condition .
ep is seen more frequently in females than males ( 3:1 ) ; it tends to occur in the third as well as in the sixth decade .
the lesions may be single or multiple , mainly affecting the legs , arms , trunk , and face in decreasing order .
histopathologically , lobules and septa are intensely infiltrated with eosinophils associated with other inflammatory cells .
a 6-year - old girl presented with complaint of a solitary , raised skin lesion of size 15  12 cm over the back of her left knee since five months .
initially , she developed an erythematous swelling of size 1  1 cm over the site ; the swelling was insidious in onset and gradually progressive in nature .
she subsequently developed intermittent , moderate grade fever associated with chills and rigors that subsided upon taking medication .
the swelling grew to 15  12 cm size within 3 months , with tenderness , but no discharge .
however , the swelling continued to progress and within one month of surgery , the swelling progressed to 15  10 cm size , filled with pus and associated with tenderness .
magnetic resonance imaging of the swelling showed it to be cellulitis and fine - needle aspiration cytology suggested an abscess .
she again underwent incision and drainage . at the time of presentation to our centre , she had an annular plaque of size 15  12 cm having an erythematous to violaceous , raised , indurated and tender periphery and a centrally atrophied plaque extending from the lower third of thigh , involving the knee joint along with the popliteal fossa and downward up to the upper one - third of left leg [ figure 1 ] .
the center of the plaque showed three hypertrophic scar marks of the previous incision and drainage [ figure 2 ] .
she had no history of trauma , insect bite , no atopic diathesis such as seasonal rhinitis or atopic dermatitis , contact dermatitis , morning stiffness of the joint , raynaud 's phenomenon , thyroid disorder , vitiligo , or alopecia areata .
annular plaque with erythematous to violaceous , raised , indurated periphery and centrally atrophied plaque over the left lower limb involving the entire knee joint and posterior aspect of the upper leg post - treatment photograph showing flattening of plaque and reduction of erythema with center of the plaque showing three hypertrophic scar marks past history was insignificant ; there was no history of consanguinity and the patient was delivered as full term normal vaginal delivery .
she had leukocytosis with an erythrocyte sedimentation rate of 70 mm / h . absolute eosinophilic counts along with serum ige levels were within normal limits .
her thyroid profile showed raised serum total t3 level ( 225.5 ng / dl ) along with raised free t3 level ( 4.6 pg / ml ) .
her blood sugar , antinuclear antibodies , renal function and liver function tests were within normal limits . rheumatoid arthritis factor and c - reactive protein were negative .
serology for human immunodeficiency virus ( hiv ) i and ii by combi - aids kit was negative .
skin biopsy confirmed a diagnosis of eosinophillic panniculitis showing infiltration of eosinophils in subcutaneous fat [ figure 3 ] . in our case , no definitive causative factor for panniculitis was found .
patient was given oral antibiotic for 1 week before 1 month of reporting to us .
it was tapered after every 15 days by 10 mg , which got completed after 6 weeks and also we had put her on tablet dapsone 50 mg daily for a period of 1 month .
orthopedic referral was made , and she was advised physiotherapy for the left knee to which she showed good response .
the treatment was then stopped ; the patient was advised monthly follow up for 6 months that was uneventful .
photomicrograph showing infiltration of eosinophils in septa and lobules of subcutaneous fat shown with the help of arrow ( h and e , 400 )
ep is seen more frequently in females than males ( 3:1 ) and mainly occurs in two age peaks - third decade and sixth decade and above .
it may be associated with a variety of conditions such as erythema nodosum , immune complex mediated vasculitis , atopic dermatitis , refractory anemia , chronic recurrent parotitis , leukocytoclastic vasculitis , drug reactions , eosinophilic cellulitis , insect bites , toxocariasis , gnathostomiasis , fasciola infection , hiv , specific immunotherapy with aqueous lyophilized bee venom , injection site reactions , trauma , and in patients with lymphoma . in some rare cases , no obvious underlying condition can be detected .
it is believed that immunodeficiency due to hematologic disease , or a trigger such as insect bite , drug intake , or viral infection induces cytokine production with an excess of interleukin-4 ( il-4 ) and il-5 , causing an altered immune response .
histopathologically , lobules , and septa are intensely infiltrated with eosinophils and may also be associated with other inflammatory cells .
some were associated with kimura 's disease , hypersensitivity to calcium , heparin , hiv with kaposi 's sarcoma - like plaques , chronic lymphocytic leukemia and cutaneous gnathostomiasis . to the best of our knowledge ,
this is the only report of ep in a pediatric patient with an idiopathic origin .
treatment for this disease is difficult and recurrences are also common . in most cases ,
it is a self - limiting disorder and has been shown to respond to prednisone as well as to dapsone .
we report this case as we could not identify a causative factor in spite of exhaustive investigations .
eosinophilic panniculitis ( ep ) is characterized by prominent infiltration of subcutaneous fat with eosinophils . 
 the etiology is diverse . 
 this is not a disease but represents a reaction pattern that may occur in a variety of circumstances . 
 the exact pathogenesis of the disease is still unclear . 
 we present the case of a 6-year - old girl child who was diagnosed with ep .