Polyarthritis and Subcutaneous Nodules Associated with Carcinoma of the Pancreas

Abstract

A 52-year-old male developed subcutaneous nodules and polyarthritis in association with an acinar cell carcinoma of the pancreas. The arthritis did not respond to aspirin, phenylbutazone, indomethacin or corticosteroid therapy. Typical changes of pancreatic enzyme-induced injuries in the subcutaneous nodules and around the joints were found at autopsy.Inflammatory polyarthritis may be a manifestation of systemic disease. O n e of the more unusual examples of this is the arthritis associated with pancreatic disease. T h e association of subcutaneous fat necrosis with pancreatitis was first reported by Chiari in 1883 ( I ) and Hansemann in 1889 (2). In 1914 .Jenckel (3) reported an articular component as part of this syndrome. In 1908 ;I similar syndrome associated with pancreatic malignancy was reported by Berner (4). T h e following is the fourteenth reported case of polyarthritis associated with acinar cell Carcinoma of the pancreas (4, 14, 1-5. 17-26). CASE REPORTW W , a 52-year-old black male was admitted for the second time to the Washington VA Hospital in June 1971 with chronic complaints of lethargy and weakness. and a Iweek history of painful swelling of his right elbow and left pretibial area. T h e patient had a history of chronic alcoholism and the diagnosis of chronic pancreatitis with pseudo- cyst was made on his first admission 3 months earlier, but the patient refused exploratory surgery at that time. At the time of his present admission he was extremely cachectic with a pulse rate of 108 he;its/min. blood pressure 116/78. respiration 24/min and a tempewture of 101" F. A left upper quadrant nontender mass previously felt to he a pancreatic pseudocyst was still present. There was fluctuant swelling, tenderness and m;irked heat over his right elhow. There was a swollen warm nodule distal to the left knee. T w o days later he was noted to have swellinq. warmth and tenderness around his left second and third metacarpophalangeal (.M<:P) joints. Aspiration of the right elbow yielded purulent fluid, leading to an initial diagnosis of septic arthritis. Antibiotic (Keflin", later ampicillin) and antiinflammatory agents (phenylbutamne, later indomethacin) were instituted and there was gradual improvement in his articular symptoms and fever over the following 2 weeks. T h e nodule on the left leg developed spontaneous purulent drainage which persisted over the ensuing 8 months. Initial laboratory data included: hematorrit 20%, WBC 2O,OOO/cu mm, rheumatoid factor-negative.erythrocyte sedimentation rate (ESR) Westergren 77 mm/hr, uric acid 6.9 mg%, calcium 10.8 mg%, phosphorus 4.2 mg%, amylase 150 and 300 Somogyi Units on two determinations and lipase 26.9 TietzBorden Units (normal: < 2). Routine bacteriologic. acidfast and fungal cultures of .joint fluid were negative. T w o months after admission the patient had an exploratory laparotomy at which time a pancreatic carcinoma with hepatic metastases was discovered. T h e patient remained in the hospital over the next 4 months receiving only supportive care. Six...

Poliartrite e nódulos subcutâneos como primeira manifestação de carcinoma de pâncreas

“…Sugere-se que esteja relacionado à lipase pancreática oriunda da hipersecreção de células acinares tumorais, ou resultante de obstrução ductal em razão de pancreatite edematosa concomitante (8) . Uma vez na circulação sistêmica, ocorre autodigestão de gordura subcutânea periarticular (1,5) e de outros sítios, onde, posteriormente, a lipase vem a ser ativada (3,12,13) , desencadeando reação inflamatória.…”

“…Em 1908, Berner relatou síndrome similar, porém associada com malignidade pancreática (1)(2)(3)(4)(5) . Em 1914, Jenckel relatou o componente articular como parte dessa síndrome.…”

“…Em 1914, Jenckel relatou o componente articular como parte dessa síndrome. Artrite, paniculite e doença pancreática têm sido encontradas formando uma rara tríade, ocorrendo em menos de 1% dos pacientes com pancreatite aguda ou carcinoma pancreático (1,6) .…”

“…Poliartrite pode ocorrer como manifestação de vários processos patológicos, podendo ser encontrada em associação à doença pancreática (1) , porém raramente o quadro de artrite antecede o diagnóstico de uma doença pancreática silenciosa (2,3) .…”

“…Em 1914, Jenckel relatou o componente articular como parte dessa síndrome. Artrite, paniculite e doença pancreática têm sido encontradas formando uma rara tríade, ocorrendo em menos de 1% dos pacientes com pancreatite aguda ou carcinoma pancreático (1,6) .Poliartrite pode ocorrer como manifestação de vários processos patológicos, podendo ser encontrada em associação à doença pancreática (1) , porém raramente o quadro de artrite antecede o diagnóstico de uma doença pancreática silenciosa (2,3) .Necrose gordurosa subcutânea tem sua origem ainda pouco esclarecida. Sugere-se que possa estar relacionada a um processo de degradação do tecido adiposo pela liberação de enzimas pancreáticas.…”