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Pancreatitis, panniculitis and polyarthritis (PPP) syndrome
  1. Geetha Swarna Devineni1,
  2. Nafiya Muhammed Zackariah2,
  3. Sudhindran Surendran3 and
  4. Malini Eapen4
  1. 1Department of General Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
  2. 2Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
  3. 3Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
  4. 4Department of Pathology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
  1. Correspondence to Professor Sudhindran Surendran; sudhi{at}


A young male presented with intermittent high-grade fever, asymmetric polyarthritis and erythematous, tender nodules over left shin for 2 months duration. He had a history of alcohol dependence with multiple episodes of acute pancreatitis. With polyarthritis progressing relentlessly, unresponsive to non-steroidal anti-inflammatory drugs and steroids, a provisional diagnosis of sarcoidosis was considered. Indeed, he was treated with azathioprine and rituximab with no effect. Biopsy of the skin nodule revealed subcutaneous fat necrosis, foam cells, deposition of eosinophilic amorphous material and calcification. Synovial fluid aspiration from the arthritic knee obtained purulent but surprisingly culture-negative material, rich in triglycerides. Abdominal CT confirmed chronic pancreatitis. Final diagnosis of pancreatitis, panniculitis and polyarthritis (PPP) syndrome was made. He underwent surgical pancreatic ductal drainage leading to complete remission of symptoms. PPP syndrome triad occurs due to leakage of pancreatic enzymes into systemic circulation and subsequent fat necrosis. Surgical drainage of pancreatic duct is often curative.

  • Gastrointestinal system
  • Musculoskeletal and joint disorders
  • Pancreatitis
  • Musculoskeletal syndromes

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  • Contributors GSD, NMZ, SS and ME were responsible for drafting the text, sourcing and editing the clinical images, investigating the results, drawing original diagrams and algorithms, and critical revision of important intellectual content. SS gave final approval for the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.