Pancreatitis, panniculitis, and polyarthritis syndrome complicated with terminal pancreatic adenocarcinoma managed with intra‐articular knee aspiration, intra‐articular lidocaine and corticosteroid injection, and decompression of panniculitis: A case report

Abstract Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome is a rare triad of hyperlipasemia, erythematous cutaneous nodules, and oligo‐ or mono‐arthritis and a rare complication of pancreatic diseases. The treatment for PPP syndrome complicated by untreatable pancreatic diseases can be challenging because the causal treatment may not be available. Herein, I report a case of a 72‐year‐old man presenting with PPP syndrome, complicated by untreatable terminal pancreatic adenocarcinoma, who was successfully managed with intra‐articular knee aspiration, intra‐articular injection of lidocaine and corticosteroid, and decompression of panniculitis.

on the extremities and buttocks. He said, "I have extreme severe burning knee pain. I cannot walk due to the pain despite I have the energy to walk." The symptoms appeared 3 weeks prior, after the cessation of the chemotherapy, and these symptoms further worsened. His body temperature was 36.2°C, blood pressure was 104/75 mm Hg, pulse rate was 82 beats/min, and oxygen saturation as measured by pulse oximetry was 97% on room air. On physical examination, the left knee was markedly swollen, while the right knee was mildly swollen (Figure 1). He had multiple painful reddish nodules (size 10-50 mm) on the extremities and buttocks ( Figure 2).
The blood laboratory test revealed white blood cell count of 9060/ µL (normal range, 3300-8600/µL), C-reactive protein level of 11.27 mg/dL (normal range, 0.00-0.14 mg/dL), lipase level of 6847 U/L (normal range, 11-59 U/L), and thyroid-stimulating hormone level of 1.04 µIU/mL (normal range, 0.50-5.00 µIU/mL). The autoimmunity profile (antinuclear antibodies, rheumatoid factor, and anticyclic citrullinated peptide antibody), parvovirus B19 immunoglobulin M antibodies, hepatitis C virus antibodies, and hepatitis B surface antigens were negative. The synovial fluid appeared cloudy At the first visit, the patient was treated with long-acting oxycodone 20 mg, betamethasone 1 mg, loxoprofen 180 mg, and short-acting oxycodone 2.5 mg as required. Despite treatment, the patient experienced extremely severe knee pain (numeric rating scale [NRS]: 10/10) and was not able to walk. He was also unable to sleep well because of panniculitis on his buttocks. I gradually increased the dosage of the medications, long-acting oxycodone 80 mg, betamethasone 4 mg, loxoprofen 180 mg, and short-acting oxycodone 10 mg as required. However, he still experienced knee pain (NRS: 6-8/10) and was unable to walk by himself. Although I prescribed him a topical steroid ointment for panniculitis, it was ineffective. I initiated bilateral knee aspiration and intra-articular knee injection of triamcinolone 40 mg and lidocaine 50 mg. After the procedure, his pain was significantly reduced (NRS: 1-3/10) and he was able to walk. However, the effect lasted only for 3-5 days. To alleviate pain, I performed knee aspiration and lidocaine intra-articular knee injection every week, and triamcinolone intra-articular injection every month. I introduced an air mattress and automated re-positioning bed for the decompression of panniculitis. The patient reported that the bed was helpful to reduce pain, and he was able to sleep well.
These measures enabled him to walk and sleep well until his overall condition declined because of the progression of pancreatic cancer. Pancreatic cancer is the fourth leading cause of cancer death in Japan, and the number of cases is increasing. 6 Hence, the need for palliative care for pancreatic cancer patients is also increasing.

| D ISCUSS I ON
Knowledge regarding PPP syndrome as an important complication of pancreatic cancer is essential to offer optimal treatment. This case shows that intra-articular aspiration and injection of corticosteroid and lidocaine and decompression of panniculitis can be the palliative treatment options for PPP syndrome.

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.

I N FO R M E D CO N S E NT
The patient provided informed consent for this case report and the photographic content use. (Figure1.2).