Pancreatic Panniculitis — SCE Dermatology MCQ
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Correct answer: C — Polyarthritis from periarticular fat necrosis (PPP syndrome)
The correct answer is C, polyarthritis from periarticular fat necrosis (PPP syndrome). Pancreatic panniculitis with lobular fat necrosis and ghost cells on histology occurs when circulating pancreatic lipase and trypsin cause enzymatic fat necrosis both in the subcutis and, less commonly, around joints and within bone marrow. When panniculitis, pancreatic disease and polyarthritis coexist, this constitutes the recognised PPP (pancreatitis, panniculitis, polyarthritis) syndrome, and joint aspirates in this setting classically contain lipid droplets and necrotic fat rather than crystals or organisms. The distinguishing clue in the stem, a tender nodule with lobular panniculitis and ghost cells in a patient with pancreatic disease, points directly to this triad rather than to any autoimmune connective tissue process. Why the other options are wrong: D. Alopecia: not a recognised feature of pancreatic panniculitis; scarring alopecia relates to conditions such as discoid lupus or lichen planopilaris, not fat necrosis from pancreatic enzymes. B. Malar rash: this is characteristic of systemic lupus erythematosus, which has a different immunological mechanism (autoantibody mediated) and no link to pancreatic lipase driven fat necrosis. E. Splinter haemorrhages: these suggest infective endocarditis or vasculitic/embolic nail bed disease, unrelated to enzymatic fat necrosis from pancreatic disease. A. Oral ulcers: seen in Behcet disease, coeliac disease or inflammatory bowel disease; there is no established association between pancreatic panniculitis and mucosal ulceration. Key point: Ghost cells on biopsy of panniculitis in a patient with pancreatic disease should prompt you to look for accompanying polyarthritis, as this triad defines PPP syndrome and warrants urgent pancreatic imaging.
Reference: DermNet NZ, Panniculitis associated with pancreatic disease, https://dermnetnz.org/topics/pancreatic-panniculitis