Letter to the Editor
Pancreatic ascites as a presentation of pancreatitis, panniculitis and polyarthritis syndrome
Ascitis pancreática como forma de presentación del síndrome de pancreatitis, paniculitis y poliartritis
Antonio Bustos-Merlo
, Laura Gallo-Padilla, Jessica Ramírez-Taboada
Corresponding author
Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves. Granada, Spain
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Granada, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ascitis pancreática como forma de presentación del síndrome de pancreatitis, paniculitis y poliartritis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1178 "Ancho" => 2462 "Tamanyo" => 560520 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Skin with lobular panniculitis featuring extensive fat necrosis with intense neutrophilic inflammatory infiltrate, basophilic cells corresponding to fat "ghost" cells, and lipophages.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute pancreatitis is a pancreatic inflammatory process, the main causes of which are gallstones and alcohol consumption. Eighty to 85% of pancreatitis have a mild course, while the remainder develop local complications or even multi-organ failure.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a male patient with a personal history of high-risk alcohol consumption who presented to the emergency department with increased abdominal girth and pain, which was eventually diagnosed as pancreatitis, panniculitis and polyarthritis (PPP) syndrome.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 55-year-old man with a personal history of active smoking (pack-year index [PYI] 40 packs/year) and regular alcohol consumption (six to seven standard drink units [SDU] per day), presented to emergency department with a 1-week history of abdominal distension, hyporexia and postprandial fullness. Associated abdominal pain in the umbilical region and episodes of diarrhoea with more than five bowel movements per day. Weight gain of 3 kg. Physical examination showed a blood pressure of 123/86 mmHg with a heart rate of 89 bpm. Peripheral oxygen saturation of 95%, FiO<span class="elsevierStyleInf">2</span> at 21%. Acceptable general condition with slight cutaneous and mucosal dehydration. No lymph nodes were palpable. Cardiac auscultation showed rhythmic tones, without murmurs. Round, distended abdomen, painless on deep palpation. Hepatomegaly of three finger breadths with ascitic fluid wave. Lower limbs with painful, erythema nodosum, 1–3 cm in diameter, predominantly affecting the pretibial surface of both lower limbs. Arthritis of both ankles and first toe of left foot. Laboratory tests showed hyperglycaemia (195 mg/dL) with elevated amylase and lipase (1452 and 2268 U/L, respectively) and acute phase reactants (<span class="elsevierStyleSmallCaps">C</span>-reactive protein 367 mg/L, procalcitonin 0.76 ng/mL, leucocytes 22,450/μL and fibrinogen 1,135 mg/dL. Abdominocentesis was performed with peritoneal fluid analysis which was compatible with ascites of pancreatic origin (leucocytes > 500/μL, > 50% polymorphonuclear, amylase levels > 80,000 U/L, proteins > 3 g/dL). He was admitted to the ward to complete the study and the following complementary tests were requested: abdominal computed tomography (CT) with significant ascites of free distribution, diffuse reticulation of the omental fat with micronodular images, small lymphadenopathies in the hepatoduodenal ligament of rounded morphology of 10 and 8 mm short axis, pancreas with signs of acute inflammatory process and parietal thickening causing significant narrowing of the lumen of the antrum, with an extension of about 6 cm. In view of the suspicion of peritoneal carcinomatosis, upper gastrointestinal endoscopy and endosonography were performed to take biopsies. Skin biopsy of the described lesions was also performed. Pathology reported chronic antral gastritis and changes suggestive of chronic pancreatitis. The skin specimen showed lobular panniculitis with extensive fat necrosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The study was extended by positron emission tomography/computed tomography (PET/CT) with no suspicious data of tumour activity. After an extensive study, a diagnosis of PPP syndrome and secondary ascites as a form of presentation was made. The patient progressed favourably after intensive fluid therapy, early enteral nutrition and non-steroidal anti-inflammatory drugs. In addition, insulin therapy for diabetes mellitus (type 3c) and pancreatic enzyme replacement therapy was instituted.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">PPP syndrome is a rare entity that is mainly associated with acute or chronic pancreatitis and, to a lesser extent, pancreatic tumours. It is more common in middle-aged men with a history of chronic alcoholism. The pathogenesis of the remote symptoms is still unclear, but the hypothesis is that massive release of pancreatic enzymes into the systemic circulation leads to subcutaneous fat necrosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Pancreatic panniculitis occurs in approximately 2–3% of cases, predominantly in the legs.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Polyarthritis has been reported in up to 54–88%. The most commonly affected joints are the ankles, wrists and small joints of hands and feet, usually symmetrically, and 25–30% manifest before abdominal symptoms.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The mortality rate of PPP syndrome associated with acute and chronic pancreatitis is approximately 24%, while that associated with pancreatic cancer is nearly 74%.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is important to know about this association because early recognition and initiation of treatment appear to be the only factors that determine the outcome of pancreatic and joint disease.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0030" class="elsevierStylePara elsevierViewall">Informed consent was obtained for imaging and subsequent publication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">This work has not received any funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1178 "Ancho" => 2462 "Tamanyo" => 560520 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Skin with lobular panniculitis featuring extensive fat necrosis with intense neutrophilic inflammatory infiltrate, basophilic cells corresponding to fat "ghost" cells, and lipophages.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of severe acute pancreatitis: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N. Gliem" 1 => "C. Ammer-Herrmenau" 2 => "V. Ellenrieder" 3 => "A. Neesse" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000506830" "Revista" => array:6 [ "tituloSerie" => "Digestion" "fecha" => "2021" "volumen" => "102" "paginaInicial" => "503" "paginaFinal" => "507" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32422634" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pancreatic panniculitis and polyarthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Zundler" 1 => "D. Strobel" 2 => "B. Manger" 3 => "M.F. Neurath" 4 => "D. 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Gildenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cutis" "fecha" => "2018" "volumen" => "101" "paginaInicial" => "E34" "paginaFinal" => "E37" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29529121" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics, treatment, and outcome of pancreatitis, panniculitis, and polyarthritis syndrome: a case-based review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Betrains" 1 => "W. Rosseels" 2 => "E. Van Mieghem" 3 => "S. Vanderschueren" 4 => "J. 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González-Naranjo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/RHU.0000000000000181" "Revista" => array:6 [ "tituloSerie" => "J Clin Rheumatol" "fecha" => "2014" "volumen" => "20" "paginaInicial" => "433" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25417680" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016200000005/v1_202403010948/S2387020624000548/v1_202403010948/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016200000005/v1_202403010948/S2387020624000548/v1_202403010948/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624000548?idApp=UINPBA00004N" ]
