Unusual presentation of pancreatitis with extrapancreatic manifestations

Abstract

Pancreatitis, panniculitis and polyarthritis syndrome (PPP syndrome) is a rare and complex manifestation of pancreatitis that is currently reported in few cases. We present this case regarding a 77-year-old man who presented unusually with a 6-week history of bilateral lesions on his lower limbs. During this time, he experienced increasing fatigue, joint pain, and reported fevers and significant weight loss. An incidental serum amylase was found to be significantly elevated and remained elevated throughout his 2-month hospital stay. He never complained of abdominal pain or other typical symptoms of pancreatitis. Histological examination of the leg lesions reported evidence of fat necrosis and changes consistent with pancreatic panniculitis. An abdominal CT scan revealed a well-defined lesion posterior to the neck of the pancreas. Further examination by endoscopic ultrasound revealed chronic inflammatory changes. The patient experienced a long admission and was managed supportively until he was well enough to be discharged home.

Keywords: pancreas and biliary tract; pancreatitis.

Figure 1

Lower right limb showing cutaneous lesions.

Figure 2

Lower right limb showing cutaneous lesions.

Figure 3

Fluctuation of serum amylase levels throughout the course of admission.

Figure 4

Histological section of deep tissue biopsies from lower limb.

Figure 5

Radiograph of the left hand showing mid-shaft bony destruction and deviation of the middle phalanx.

Figure 6

CT scan of the abdomen with intravenous contrast, showing a lesion posterior to the neck of the pancreas.