A PANCREATIC MASS SECONDARY TO GRANULOMATOUS PANCREATITIS DUE TO CANDIDA GLABRATA FUNGEMIA

Abstract

A 72 year-old man was transferred to our institution for ERCP following a failed attempt at common bile duct stone extraction. He was well until six months prior to transfer when he was hospitalized for gallstone-induced pancreatitis, which was complicated by the development of a deep venous thrombosis and Candida glabrata fungemia. After transfer he underwent an ERCP with commonbile duct stone extraction followed by laparoscopic cholecystectomy. A CT scan done for persistent midepigastric abdominal pain revealed a 4 × 4 cm phlegmonous area at the head and body of pancreas with peripancreatic fat stranding. Two weeks later a follow-up CT of the abdomen revealed a 5 cm pancreatic head mass with interval cystic degeneration centrally. A CT guided biopsy and aspiration of the pancreatic mass was performed one week later due to persistent abdominal symptoms and worsening back pain. Almost immediately after the procedure the patient developed severe back pain and this rapidly progressed to weakness, numbness and decreased sensation of the lower extremities bilaterally. A magnetic resonance imaging revealed thoracic spinal cord compression as a result of exuberant diskitis and osteomyelitis at the level of T 10 – 11. Neurosurgery was performed with necrotic bone and pus identified at the level ofT10-11.A subsequent partial vertebrectomy was performed. The patient was placed on an antibiotic regimen with vancomycin, cefepime, and amphotericin. Subsequent results of the pancreatic biopsy showed the presence of granulomatous pancreatitis. The cultures from the vertebral tissue and pancreatic aspiration both revealed Candida glabrata. Substantial clinical improvement was noticed and finally the patient was discharged. Granulomatous pancreatitis is an uncommon entity whose etiologies include inflammatory bowel disease, fungal infections, sarcoidosis, tuberculosis, foreign bodies and medications, i.e. 6-mercaptopurine, azathioprine and sulfasalazine. It is not usually considered in patients with a pancreatic mass or cystic lesion. The aim of this report is to describe its diagnosis by CT guided parenchymal biopsy which subsequently can lead to more directed therapies. Also the use of EUS or CT guided pancreatic biopsy will allow earlier diagnosis and directed therapy and could decrease morbidity and mortality.