Acute pancreatitis presenting with polyarthritis
The following case appears in the Indian Journal of Rheumatology.

A 47-year-old man presented with symmetrical polyarthritis affecting knees, ankles, wrist joint, and right thumb for 2 weeks. On examination, the joints were swollen, erythematous, and tender. He was initially treated as septic arthritis. Thick pus was aspirated from the knee joints. He was empirically started on broad-spectrum intravenous antibiotics (meropenem and vancomycin) and had undergone arthrotomy and lavage of the knees for septic arthritis.

Two months earlier, he had been treated conservatively for alcohol-related acute pancreatitis and computed tomography (CT) abdomen at that time showed an enlarged pancreas. He had also undergone surgery for pancreatic pseudocyst 5 years back.

As there was no improvement we considered the possibility of pancreatitis panniculitis polyarthritis (PPP) syndrome. Although the patient did not have abdominal pain at presentation, CT abdomen revealed a pancreatic pseudocyst. His serum amylase was elevated (3946 IU/L).

This patient did not have clinical findings of panniculitis, but his synovial fluid examination showed fat globules. MRI of his hands and feet showed intramedullary fat necrosis. The patient underwent a cystogastrostomy for the pancreatic pseudocyst 3 weeks after the onset of the polyarthritis.

His subsequent serum amylase levels were 420 IU/L. His joint swelling subsided after 2 weeks with moderate residual restriction of joint movements.

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