Rare complications of ERCP-pancreatitis, panniculitis, and polyarthritis syndromeand multifocal osteomyelitis.

Severe pancreatitis following retrograde cholangiopancreatography (ERCP) is an infrequent occurrence. Even rarer are the additional non-pancreatic symptoms that can emerge after ERCP-induced pancreatitis, such as panniculitis and polyarthritis. This combination of symptoms is recognized as the pancreatitis, panniculitis, and polyarthritis syndrome (PPPS). PPPS typically manifests as reddish subcutaneous nodules, primarily in the lower extremities. In some cases, the condition may progress into the bones, causing intramedullary fat necrosis/bone infarcts. Joint complications involve polyarthritis and affect both small and large joints. PPPS tends to develop 3-6 weeks after the peak of clinical pancreatitis. In this report, we present a case of PPPS that occurred as a complication following ERCP. This particular case became further complicated by the presence of bacteraemia and fungaemia, leading to the subsequent development of multi-focal osteomyelitis. The medical imaging included in this report provides a comprehensive overview of the entire clinical course, starting from the initial post-procedural complication and pancreatitis, followed by multi-modal imaging depicting panniculitis using ultrasound and MRI, and finally illustrating the development of multi-focal osteomyelitis. This case serves as an opportunity to explore and understand 2 rare complications associated with pancreatitis: PPPS and multi-focal osteomyelitis.