1274 An Unusual Case of Sarcoidosis Involving the Pancreas

Abstract

INTRODUCTION: Sarcoidosis is a multisystem disease primarily involving the lung. Skin, eyes, lymph nodes, spleen, liver, bones, exocrine glands, heart, kidneys, and central nervous system are the most common extrapulmonary sites involved. Clinically apparent gastrointestinal (GI) sarcoidosis is rare involving 0.1 to 0.9 percent of patients with sarcoidosis. The most commonly involved portion of the GI tract is the stomach, although sarcoidosis of the esophagus, appendix, colon, rectum, and pancreas have been reported in the literature. CASE DESCRIPTION/METHODS: A 73-year-old African American male was found to have pancreatic duct dilation on a computed tomography scan of abdomen done for investigation of mild epigastric abdominal pain that started a few months prior to presentation. He described the pain as dull, non-radiating, aggravated when hungry, subsided with food intake and associated with bloating. He had a past medical history of hypertension, hypothyroidism, and sarcoidosis involving lymph nodes and liver (not on treatment). He had no family history of GI cancer. He was a non-smoker and non-alcoholic. On presentation, his vital signs were normal; his abdomen was soft and non-tender, with normoactive bowel sounds and no masses or organomegaly. He had a normal calcium level of 9.7 mg/dL and his liver panel was significant for slightly elevated serum alkaline phosphatase, AST, ALT levels, with normal serum bilirubin. Magnetic resonance imaging showed 1.2 cm mass in the body of the pancreas obstructing the pancreatic duct and another 1.1 cm mass in the head of the pancreas concerning for malignancy. He underwent endoscopic ultrasonography with fine needle aspiration cytology of both pancreatic masses which showed numerous non-caseating granulomas consistent with sarcoidosis. Special stains for fungi and tuberculosis were negative. DISCUSSION: Less than 30 cases of biopsy-proven pancreatic sarcoidosis have been reported in the literature. Patients can have direct involvement of pancreas with sarcoidosis or 1, 25-dihydroxy vitamin D3 mediated hypercalcemia causing hypercalcemic pancreatitis. About three fourths of patients with pancreatic sarcoidosis have bilateral hilar adenopathy on chest radiography. On imaging, these patients demonstrate either a pancreatic mass (or masses) or a diffuse nodular pancreas. A biopsy is essential to distinguish between sarcoidosis, mycobacterial or fungal infection, and cancer. Treatment is usually conservative or with glucocorticoids.