PMC5288313_01
Development of lipase levels. Normal: 73-393 U/l. Treatment for reactive arthritis was 20 mg prednisolone + doxycycline. Operation: Surgical resection of pancreatic pseudocyst.
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Laboratory tests showed extremely high levels of plasma lipase up to 232.000 U/l (normal: 73-383 U/l) and alpha-amylase up to 11920 U/l (normal: 25-115 U/l) (Fig. 1). Postoperative plasma levels of lipase dropped immediately and permanently to normal levels, which confirmed the diagnosis (Fig. 1).
2-phase bone scintigraphy (late phase). Symmetric polyarthritis of the extremity skeleton, but atypical intense uptake in the left proximal tibia (arrow).
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There was also a striking intense uptake in the clinically highly affected left proximal tibia with a central gap (mark in Fig. 2) which is not typical for arthritis.
MR-Imaging of knee and ankles demonstrated multiple 'infarct like' bone necrosis near joints of prox. and distal tibia, calcaneus, talus and all tarsal bones. Diffuse contrast agent uptake of surrounding soft tissue.
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Further examination showed similar lesions in both distal tibiae, calcaneus, talus and all tarsal bones (Fig. 3).
Abdominal MRI (A, B) depicted a pseudocyst of the uncinate process of the pancreas. The cystic lesion shows a direct connection to the superior mesenteric vein on the contrast enhanced T1 weighted images (A) as well as on the T2 weighted images (B) (arrow in A and B). The connection between the cyst and the superior mesenteric vein was also detectable on a contrast enhanced CT study which was performed one week prior to the MRI examination.
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Magnetic resonance and computed tomography of pancreas and biliary tract showed a cystic lesion in the pancreas head with a diameter of 1.3 cm and a partial thrombosis of the superior mesenteric vein adjacent to the cyst (Fig. 4).
Operative findings showed the opened pseudocyst of the uncinated process (arrow) close to the superior mesenteric vein (SMV).  marks the altered segment of SMV with thrombosis. PH = pancreatic head.
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On surgical exploration, the pancreas presented with heavy post-inflammatory alterations of the uncinate process with a pseudocyst adjacent to the superior mesenteric vein (Fig. 5).