S1679 A Case of Polyarthritis Panniculitis and Pancreatitis (PPP) due to Recurrent Alcoholic Pancreatitis

Abstract

Introduction: Polyarthritis Panniculitis and Pancreatitis (PPP) is a rarely seen extra pancreatic morbidity hallmarked by the triad of joint pain (polyarthritis), tender skin lesions (panniculitis), and pancreatic inflammation (pancreatitis). The pathogenesis is mediated by pancreatic enzyme lipolysis of lipid rich skin and joint sites. Unfortunately, PPP is an elusive diagnosis given the minimal intrabdominal symptoms and a delayed diagnosis may worsen prognosis by as much as 24%. As such, we aim to present a case of this rare diagnosis to familiarize clinicians with the diagnosis of PPP. Case Description/Methods: 67 M with prior alcohol use disorder, recurrent pancreatitis, and complex pancreatic cyst (2.1 x 1.4 cm) status-post fine needle aspiration presented with fever, malaise, diffuse joint pain, and rash. Exam was notable for diffuse visible synovitis, tender joints, and subcutaneous nodules. Patient denied abdominal pain and was hemodynamically stable. Laboratory findings are shown in the Table. Work-up including tickborne panel, Hepatitis B & C serology, Blood cultures, Urinalysis, Chlamydia, Gonorrhea, ASO, CCP, ACE, ANA, ANCA, IgG4, SSA, and SSB were all within normal limits. Right knee aspiration revealed straw colored fluid with 8552 WBC, 86 Neutrophils, no crystals, no growth on culture, and < 3000 RBCs. CT of the Abdomen & Pelvis revealed complex cystic lesion of the pancreatic head measuring 2.2 cm, punctate foci of calcification, no pancreatic ductal dilatation, distal common bile duct within normal limits (Figure A). MRI of the left foot revealed multifocal intramedullary osteonecrosis with bone marrow edema, multifocal synovitis, and prominent intermetatarsal bursitis (Figure B and C). Skin biopsy of the right thumb revealed lobar panniculitis with necrosis of adipocytes and residual “ghost cells”. Patient was managed with IV solumedrol 80 mg, and prednisone taper. On follow-up one month later, patient’s symptoms completely resolved. Follow-up MRI of the abdomen showed stable 2 cm pancreatic cyst which was not consistent with underlying malignancy. Discussion: PPP is a potentially devastating pathology most commonly observed in males with prior alcohol use. The diagnosis often proves elusive given the lack of abdominal symptoms, but early intervention is crucial in reducing mortality and morbidities as seen in our case.Figure 1.: CT of abdomen (A) and MRI of left foot (B, C). Table 1. - Laboratory Findings Hematology Value Hemoglobin 12.2 g/dL Hematocrit 37 % White Blood Cells 12.4 K/uL Platelets 304 K/uL Chemistry Value Sodium 139 mmol/L Potassium 3.8 mmol/L Chloride 104 mmol/L Bicarbonate 26 mmol/L Blood Urea Nitrogen 18 mg/dL Creatinine 0.87 mg/dL Glucose 94 mg/dL Total Bilirubin 0.68 mg/dL Alkaline Phosphatase 69 IU/L AST 27 IU/L ALT 34 IU/L Lipase 20,521 IU/L C-Reactive Protein 14 mg/L Uric Acid 3.6 mg/dL