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SAN DIEGO—At the 2017 Thieves Market, held Nov. 6 at the ACR/ARHP Annual Meeting, rheumatologists from around the world presented patient cases to an audience of colleagues, who then voted via text messaging to choose the cases they felt were most perplexing or intriguing. The winner received a free 2018 Annual Meeting registration, and the runner-up snagged a free Meet the Professor session registration, also for the 2018 Annual Meeting in Chicago in October.
First Prize: Very Rare Extra-Pancreatic Syndrome
Marc Plier, MD, a rheumatologist at Clinique University Saint-Luc in Brussels, Belgium, won top honors for his case of a man who presented to the emergency department after four weeks of severe, widespread pain and swelling. The patient’s painful, swollen digits resembled dactylitis, and he also had a left knee effusion, fever and tender subcutaneous nodules that suggested panniculitis. Aspiration of the swelling on his hands showed a creamy, yellow fluid that looked like liquefied fat, said Dr. Plier. Knee aspiration revealed that the patient had a great deal of fluid in the joint, but no crystals. He had very high C-reactive protein levels and slightly elevated uric acid, but other laboratory test results were normal. Because of his severe pain, Dr. Plier and his colleagues ordered an arthroscopy, which showed unusual bits of free-floating fat in his joint. A synovial biopsy showed a lesion that indicated fat necrosis.
To diagnose what processes caused the patient’s bone, skin and joint manifestations, physicians measured his serum and synovial fluid lipase levels and found they were highly elevated. An abdominal CT scan showed a large duodenal mass, and the patient was diagnosed with primary pancreatic-type acinar cell carcinoma, which led to another diagnosis of PPP syndrome (i.e., pancreatitis, panniculitis and polyarthritis syndrome). This extremely rare condition has been reported in only about 60 cases worldwide, and half the time it’s related to an underlying pancreatic tumor, said Dr. Plier.
Runner-Up: Blurred Vision, Rash, Muscle Weakness
Tamara Dahhan, DO, a rheumatology fellow at Olive View-UCLA Medical Center in Sylmar, Calif., took runner-up honors with her case of a 50-year-old man with acute-onset, right upper-extremity weakness and numbness that had persisted over the previous 12 hours. For a week prior to coming to the hospital, the patient had experienced blurry vision in his right eye that was painless and progressive. He also had a red, nonpruritic rash over the bilateral lower extremities that had lasted for four months. Originally from Mexico, the patient had been living in the U.S. for 20 years and had visited his hometown about six months before coming to the hospital.