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Case Reports

Abstract

Pancreatitis, panniculitis, and polyarthritis (PPP) are underrecognized systemic syndrome that may be associated with pancreatic acinar cell carcinoma. PPP can present in the absence of abdominal symptoms, and early recognition of pancreatic panniculitis as the presenting sign of PPP can be crucial in the early detection and management of underlying pancreatic malignancies. We report a case of a 62-year-old female who presented with intermittent lower extremity swelling, painful nodules, and red patches on the bilateral shins. She also reported polyarthritis with no other systemic symptoms. On examination, there were 2-6 cm tender pink nodules with a shiny appearance and hair loss on bilateral anterior shins. A skin biopsy of the left medial shin showed thickening of the fibrous septae of the subcutaneous fat and a mixed inflammatory infiltrate consisting of lymphocytes, histiocytes, eosinophils, and neutrophils, compatible with erythema nodosum. PAS and AFB stains were negative for fungal and mycobacterial organisms. Additional studies with Von-Kossa stain highlighted focal areas of degenerated feathery changes suggestive of early pancreatic panniculitis. Recommended CT imaging studies identified a mass in the pancreas, leading to a diagnosis of pancreatic acinar cell carcinoma. This case illustrates that early pancreatic panniculitis can present with changes of erythema nodosum-like septal panniculitis rather than classic lobular changes. It's also essential to recognize pancreatic panniculitis as a presenting sign of PPP syndrome. Lastly, this case emphasizes the importance of clinicopathologic correlation in facilitating early detection of a potential pancreatic malignancy.