Introduction
Pancreatic panniculitis is a rare disease involving fat necrosis in the panniculus in association with pancreatic disease. The rarity of this condition is best described by Mullin et al. who reported one case of panniculitis out of 893 patients with various pancreatic diseases ¹. We report a man presenting with panniculitis, pancreatic tumour and polyarthritis with a fatal outcome. Awareness of the rare skin manifestation observed and the potentially fatal consequences, can guide physicians to rapid diagnosis and management.

Case presentation
An 84-year-old Caucasian man presented with a 4-week history of severe abdominal pain radiating to his back and with haematuria. He was receiving long-term warfarin treatment for atrial flutter and his international normalised ratio on admission was 17.6. He complained of nausea and weight loss, but reported no recent change in bowel habit. On examination, the patient was cachectic and pyrexial. He had epigastric and right upper quadrant tenderness. Of note was swelling of his right carpometacarpal, bilateral thumb and index finger metacarpal joints. Laboratory investigations revealed a white-cell count of 12.6 × 109/L, C-reactive protein of 198 mg/L, gammaglutamyl transpeptidase of 273, raised serum lipase of 17362 U/L and serum amylase of 619 U/L. Chest and abdominal X-rays were normal. The abdominal computed tomography (CT) scan showed a 9 × 8 cm mixed attenuation mass initially thought to represent pancreatic head haematoma (Figure 1). The patient’s warfarin treatment was discontinued and he was managed conservatively with intravenous fluids, analgesia and bed rest. Levels of the tumour markers carcinoembryonic antigen (CEA) and CA19-9 were normal. A follow-up scan 8 weeks later revealed that the mass had not resolved and was now more likely to represent a tumour of the head of the pancreas or a pancreatic pseudocyst. The patient declined an endoscopic ultrasound.