Acute onset of Lupus associated Pancreatitis Mimicking Pancreatic Cancer

Abstract

A 42-years old caucasian woman was admitted to our hospital because of jaundice developed some days earlier. Her history was positive for mixed connective tissue disease and autoimmune thrombocytopenia treated for several months with oral corticosteroids. At admission, a contrast-enhanced CT scan of the abdomen revealed an enlargement of the head of the pancreas, marked dilation of the main bile duct and moderately dilated intrahepatic bile ducts (figure 1). An endoscopic ultrasound guided fine needle aspiration (FNA) was performed; histology was negative for neoplastic cells and immunohistochemistry with positive staining for cytokeratin (CK)19, but negative staining for Insulin-like growth factor II mRNA-binding protein (IMP)-3 together with a low (MIB)-1 labelling index (<2%) was consistent with an inflammatory process. Endoscopic retrograde cholangio pancreatography (ERCP) for biliary stenting was complicated by hemoperitoneum and the patient was transferred to the surgery unit and, subsequently, because of hemodynamic instability to the ICU. During recovery and resolution of jaundice a spontaneous free colonic perforation occurred and the patient underwent left-sided colectomy together with an ileostomy in the right hemi-abdomen. Histological evaluation of the surgical specimen was consistent with CMV infection. The patient slowly recovered and was discharged after three months. She was readmitted 1 month later because of malnutrition and dehydration; in this occasion a contrast-enhanced ultrasound (US) evaluation of the pancreas revealed no focal lesion and a globally moderately dilated main pancreatic duct consistent with chronic pancreatitis (figure 2). At this moment, repeated determination of blood glucose revealed diabetes mellitus that was treated with Insulin.