Massive subcutaneous and intraosseous fat necrosis associated with pancreatitis. Natural evolution of the radiographic picture

Subcutaneous and Intraosseous Fat Necrosis Associated with Chronic Pancreatitis

Background: Extra-abdominal manifestations of fat necrosis, like subcutaneous fat necrosis, polyarthritis, and polyserositis may appear with an occurrence rate of about 0.8%, wherein intraosseous fat necrosis is a more rare complication of pancreatitis, with few reports in English literature. Case report: A 34-year-old male with a 15-year-history of alcohol abuse was hospitalized several times in the last few years because of attacks of relapsed chronic pancreatitis. After the last attack, pancreatitis came in a stable state (“burned out”) with no symptoms and signs of the disease. The patient had been free of symptoms for 28 months since the last admission when he came with sub-febrile temperature, huge pain, swelling, and erythema in the area of the left lateral malleolar region with propagation in the foot. Blood biochemistry was normal. Conventional radiography showed multiple sites of osteolysis in the left calcaneus. Images on multislice computed tomography (MSCT) with 3D reconstruction revealed hypodense focuses that corresponded to osteonecrosis areas and bone marrow edema in the left calcaneus. Conclusions: The possibility of intraosseous fat necrosis should be considered in situations of unexplained polyarthritis or panniculitis, particularly in individuals with alcohol abuse or pancreatic disease.

Pancreatitis, Panniculitis, and Polyarthritis Syndrome Detected on 99mTc-MDP Bone Scan

ABSTRACT

Pancreatitis, panniculitis, and polyarthritis syndrome is a rare disease. A 49-year-old man recently complained of bilateral ankle and epigastric pain. An ankle x-ray showed subcutaneous soft tissue swelling. Subsequent 99mTc-MDP bone scan showed foci of abnormal activity around joints in all extremities, especially in the knees and ankles. In addition, multiple nodular calcifications in the head of the pancreas were found in the abdominal CT scan. The patient also had increased blood amylase and lipase. The symptoms were resolved after the treatment of his pancreatitis.

[A several-week history of inflammatory changes in the right foot and right hand of a 57-year-old male patient]

Metastatic fat necrosis due to inflammatory or neoplastic pancreatic diseases is rare. This phenomenon is attributed to systemic effects of pancreatic enzymes. Depending on the sites of fat necrosis, a number of different diseases may be mimicked, leading to incorrect diagnosis and therapies. Many case reports describe the phenomenon of skin, joint and bone manifestations of fat necrosis under the acronym PPP (pancreatic, panniculits, polyarthritis) syndrome. The management of "autodigestion" primarily consists of treating the underlying pancreatic disease.

Clinical characteristics, treatment, and outcome of pancreatitis, panniculitis, and polyarthritis syndrome: a case-based review

A 42-year-old Caucasian female presented with lower limb panniculitis and bilateral ankle arthritis in the absence of abdominal or other localizing symptoms. Abdominal imaging revealed subacute pancreatitis with pseudocyst formation. The clinical manifestations were compatible with pancreatitis, panniculitis, and polyarthritis syndrome (PPP syndrome), a very rare complication of pancreatic disease. The patient improved with conservative treatment for the pancreatic disease and systemic corticosteroids for the cutaneous and articular manifestations. We identified 59 patients with the PPP syndrome from the literature, the majority of patients being male (74.6%) with a median age of 49 (IQR 41-63.5) years. Acute pancreatitis is the most frequent underlying disorder (54.2%), but gastrointestinal symptoms are absent in 45.8% of patients. Pancreatic panniculitis has a predilection for the lower limbs, which are affected in 98.3% of cases. However, the cutaneous lesions may also involve the upper limbs and trunk. Arthritis is typically symmetric and polyarticular in nature, affecting both large and small joints. Of all patients who received treatment, 78.6% had a poor response. Death occurred in 27.1% of cases after a median duration of 8 (IQR 3.5-14) weeks.

Pancreatic panniculitis in a patient with pancreatic-type acinar cell carcinoma of the liver--case report and review of literature

Background

Pancreatic panniculitis is a rare condition, which has only been described in relation with pancreatic diseases up to now. It is characterized by necrotizing subcutaneous inflammation and is thought to be triggered by adipocyte necrosis due to systemic release of pancreatic enzymes with consecutive infiltration of neutrophils. We present the first case of a patient with pancreatic panniculitis caused by pancreatic-type primary acinar cell carcinoma (ACC) of the liver and without underlying pancreatic disease.

Case presentation

A 73-year old Caucasian female patient was referred to our department with painful cutaneous nodules persisting for eight weeks and with marked lipasemia (~15000 U/l; normal range <60 U/l). Four weeks prior, several liver lesions had been detected. Empiric treatment with steroids did not show any effect. A biopsy of the skin nodules revealed “pancreatic” panniculitis, while abdominal imaging with ultrasound, computed tomography and magnetic resonance imaging detected no abnormal pancreatic findings. Ultrasound-guided biopsy of the liver lesions showed infiltrates of an ACC. The patient died soon thereafter. Autopsy failed to reveal any other primary for the ACC, so that a pancreatic-type ACC of the liver was diagnosed by exclusion.

One hundred thirty cases of pancreatic panniculitis published within the last 20 years are reviewed. ACC of the pancreas is the most common underlying neoplastic condition. Patients with associated neoplasm are significantly older, take longer to be diagnosed and have higher lipase levels than patients with underlying pancreatitis.

Extrapancreatic pancreatic-type ACC is very rare, but shows the same biological features as ACC of the pancreas. It is believed to develop from metaplastic or ectopic pancreatic tissue. Up to now, no pancreatic panniculitis in extrapancreatic ACC has been described.

Conclusion

Pancreatic panniculitis should always be included in the differential diagnosis of lipolytic panniculitic lesions. It can be regarded as a facultative paraneoplastic phenomenon.

When suspected, a thorough work-up for identification of the underlying disease is mandatory and extrapancreatic lesions (e.g. liver) should also be considered. While administration of octreotide or steroids can sometimes alleviate symptoms, immediate treatment of the associated condition is the only effective management option.

Pathological fracture due to vertebral osteonecrosis associated with pancreatitis

A 50-year-old man with a history of alcohol-induced pancreatitis was admitted to a hospital with swelling and pain of the right ankle, and fever, and was suspected to have osteomyelitis. Radiographs of the fingers, ankles, and feet, in which pain and swelling were present, revealed multiple pathological fractures. The histological examination of the tissue sample in the right radius showed sequestrated fat necrosis. Bacterial culture test remained negative. Based on the findings mentioned above, a diagnosis of intraosseous fat necrosis associated with pancreatitis was made. Treatments proven to be effective in the literature for pancreatitis were started. Symptoms of the bones and joints gradually improved. However, pancreatitis relapsed, triggered by drinking, 4 months after discharge. He had complaints of back pain without any history of trauma. Radiographs showed fractures of the entire vertebral body from the 12th thoracic to 5th lumbar vertebrae. What was interesting about the present case was that, after the pathological fractures of the extremities were completely resolved, osteonecrosis relapsed as pancreatitis deteriorated, resulting in pancreatic cyst rupture into the intrathoracic cavity and vertebrae, differing from the previous lesions that were affected. There are very few cases of pathological fracture induced by pancreatitis that affect the vertebrae.

Arthralgia and osteolytic lesions associated with traumatic pancreatitis in a 10-year-old girl

A case of traumatic pancreatitis with subsequent joint pain and osteolytic lesions is presented. A 10-year-old girl was admitted to our hospital with abdominal pain caused by blunt epigastric injury. She was diagnosed with traumatic pancreatitis, and multiple pancreatic pseudocysts subsequently developed. Two weeks after admission, she complained of joint pain, and MR revealed osteolytic lesions of both knee joints. On the 58th day, endoscopic transgastric pseudocyst drainage was performed. Joint pain and osteolytic lesions resolved rapidly, in parallel with the decrease in serum amylase level and pseudocyst size.

Pancreatitis, panniculitis, and polyarthritis

BACKGROUND AND OBJECTIVE

Lobular panniculitis, together with polyarthritis and intraosseous fat necrosis, may occasionally complicate pancreatic disease. This triad is known in the literature as the pancreatitis, panniculitis, and polyarthritis (PPP syndrome). We describe a case of the PPP syndrome and review the available literature to summarize the clinical characteristics of patients with this condition.

METHODS

A patient with the PPP syndrome, with evidence of extensive intraosseous fat necrosis in the joints involved revealed by magnetic resonance imaging, is described and the relevant literature based on a PubMed search from 1970 to February 2008 is reviewed. The keywords used were pancreatitis or pancreatic disease, panniculitis, arthritis, and intraosseous fat necrosis.

RESULTS

Including our case, 25 well-documented patients with the PPP syndrome have been reported. Our patient had few abdominal symptoms despite high serum levels of pancreatic enzymes. In our review of the literature, almost 2/3 of patients had absent or mild abdominal symptoms, leading to misdiagnosis. The delay in diagnosis and specific treatment of the underlying pancreatitis worsens the prognosis of this condition, which has a mortality rate as high as 24%. In nearly 45% of the patients, the arthritis follows a chronic course with a poor response to nonsteroidal anti-inflammatory drugs and corticosteroids, and the rapid development of radiographic joint damage.

CONCLUSION

Certain forms of pancreatic disease can very occasionally cause arthritis and panniculitis. Although uncommon, physicians should be alert to the possible presence of this syndrome for 2 reasons: first, unrecognized pancreatic disease can be fatal if not treated promptly; second, to avoid inappropriate and risky therapy to improve joint symptoms.

Pretibial subcutaneous soft tissue lesions presenting to a paediatric orthopaedic clinic

Pretibial swellings in children usually represent erythema nodosum which exhibits characteristic skin changes. Three cases of pretibial subcutaneous lesions are presented which had no skin involvement or bony abnormalities on plain radiographs. At initial presentation, concerns of malignancy were raised but these lesions were ultimately diagnosed as granuloma annulare, fat necrosis and subcutaneous infection. In combination with clinical assessment and plain radiographs, MRI proved invaluable in reaching diagnosis and excluding neoplasia. Biopsy was only required in one case in this series after MRI. A tissue diagnosis, however, remains mandatory if there is any doubt over the nature of such lesions.

Panniculitis, polyarthritis and osteomyelitis associated with pancreatic neoplasia in two dogs

A 12-year-old crossbred dog (case 1) and a 12-year-old Shetland sheepdog (case 2) were presented with a history of lameness and distal limb swelling. Physical examination revealed joint effusions and asymmetrical swellings of the extremities. In case 1, a diagnosis of arthritis and cellulitis was made on fine-needle aspiration biopsy of the synovium and subcutis. In case 2, bone biopsies and synovial aspirates diagnosed osteomyelitis and arthritis. A diagnosis of pancreatic disease was made on the findings of marked elevations of serum lipase concentrations and ultrasonographic identification of pancreatic masses in both cases. Both the cases were non-responsive to symptomatic management and were subsequently euthanased. Postmortem examination confirmed the diagnosis of panniculitis, arthritis and osteomyelitis in both cases. A pancreatic exocrine adenoma was identified in case 1 and a pancreatic adenocarcinoma with widespread metastases in case 2. To the authors' knowledge the association of panniculitis, polyarthritis and osteomyelitis with pancreatic disorders has not been reported previously in canine clinical cases.

Posttraumatic Pseudolipoma (Fat Necrosis) Mimicking Atypical Lipoma or Liposarcoma on MRI

We report a case of a 53 year old female who presented with a painless mass over her left greater trochanter. Evaluation with MRI and ultimately biopsy led to a diagnosis of fat necrosis. If this diagnosis had been considered with greater confidence, a conservative approach could have been taken and biopsy avoided. In patients with lesions demonstrating classic locations and imaging features of fat necrosis, observation without biopsy is appropriate.

Retinopatía de Purtscher: complicación infrecuente de la pancreatitis aguda no alcohólica

Purtscher's retinopathy is a rare complication of acute alcoholic pancreatitis that is characterized by the development of cotton-wool exudates and retinal hemorrhages located around the optic disk. Its development is due to ischemic phenomena in the posterior pole of the retina due to microemboli in the retinal arterioles and capillaries. This complication is not related to a poorer prognosis of acute pancreatitis and the retinopathy usually has a favorable outcome with disappearance of the ophthalmic lesions and restoration of visual acuity after 4-6 weeks in most cases. However, some patients may show residual lesions, especially if optical atrophy occurs. We present a 40-year-old woman with loss of visual acuity due to Purtscher's retinopathy during the course of mild acute idiopathic pancreatitis.