Background: Pancreatic panniculitis is a very rare manifestation of a pancreatic disease. This condition was first illustrated by Mullin et al1,2, who reported 1 case of panniculitis out of 893 patients with pancreatic disease. Much more unusual, is when polyarthritis occurs with panniculitis in patients with pancreatic pathology. Literature review showed <5 absolute cases of this association2. There is no scientifically-proven mechanism of relationship of these symptoms but some studies suggested that elevated levels of enzymes from the diseased pancreas, acting synergistically with trypsin, are accountable for the rash and arthritis.5,27,28
Objective: To present a rare case of a panniculitis and polyarthritis in a patient with an underlying pancreatic disease, and to discuss it's diagnosis and management.
Setting: DLSUMC, a tertiary training hospital in Dasmariñas, Cavite.
Case Summary: This case describes a 57 year-old Filipino who complained of few painful, erythematous, nodular rash on both legs, associated with knee and ankle pain 2 weeks PTA. On admission, work-up revealed leukocytosis, anemia, elevated transaminases, alkaline phosphatase, direct bilirubin levels, amylase and CA 19-9. Abdominal CT revealed intrahepatic and pancreatic duct dilatation. Initial treatment included blood transfusion, antibiotics, corticosteroids, analgesics, and bowel rest. He underwent ERCP showing CBD and pancreatic duct stricture and cut-off demonstrating the double duct sign which lead to the diagnosis of pancreatic head tumor. Wedge biopsy of the nodules confirmed the diagnosis of pancreatic panniculitis. The join pains and rash remained but stopped progressing after endoscopic stent placement and sphincterotomy. Diet was resumed and was discharged after 18 days.
Significance: Awareness of the less common presentations of diseases is useful to avoid delay in the diagnosis and to prevent potential fatal outcomes. Such awareness applies to panniculitis and polyarthritis in pancreatic disease. Although this association is unusual, early recognition is critical because of the high mortality of pancreatic disease when the diagnosis is delayed.1,2 Importantly, this awareness also prevents misdiagnosis and administration of inappropriate treatment.