Diagnostic Dilemma: Neoplasm or Sarcoidosis? Case of Pancreatic Sarcoidosis Mimicking Pancreatic Mass

Abstract

Introduction: To present an interesting case of pancreatic sarcoidosis that presented with clinical and radiographic findings suggestive of pancreatic neoplasm. Sarcoidosis is an idiopathic multisystem inflammatory disease characterized by the formation of nonnecrotizing granulomas in the affected organs. Lungs are the most commonly affected organs. Pancreatic involvement is extremely rare. Case Report: A 60-year-old African American man presented with complains of unintentional weight loss of 30 pounds, anorexia, and abdominal pain for 6 months. Past medical history was significant for intermittent asthma controlled with as needed Albuterol MDI. Twelve-point review of system was unremarkable. Family history was positive for lung cancer and heart disease. Ultrasonography revealed 5-cm hypoechoic peripancreatic mass. CT and MRI scan of the abdomen showed multiple masses in the same region with multiple peripancreatic enlarged lymph nodes with patent pancreatic and hepatic ducts. The patient underwent laparotomy with excision of the mass and the surrounding lymph nodes. Surprisingly the pancreatic mass and lymph nodes showed nonnecrotizing inflammation. Fungal and AFB stains were negative for organism. Chest x-ray revealed mediastinal and bilateral hilar lymphadenopathy without lung infiltrates. Diagnosis of sarcoidosis with pancreatic and pulmonary involvement was made. His symptoms resolved without any treatment. Patient was doing well after 6 months’ follow-up. Discussion: Gastrointestinal (GI) system affliction in sarcoidosis is uncommon. GI involvement is most commonly in stomach. One report that reviewed 9 major series found pancreatic granulomas in 3 out of 287 postmortem examinations.[1] Yamaguchi and et al found only 26 reported cases of pancreatic sarcoidosis.[2] The pancreatic sarcoidosis may present along with systemic disease or as an isolated finding. It can be frequently asymptomatic to can present with nonspecific systemic symptoms. Two-thirds of the patients with pancreatic sarcoidosis have abdominal pain, and three-quarters of them have bilateral hilar adenopathy. The occurrence of abdominal pain in a patient with bilateral hilar adenopathy should lead one to think of pancreatic sarcoidosis. The ultimate diagnosis should be established by a tissue biopsy. The treatment is needed only if patient has symptoms. Treatment of choice is prednisone. The prognosis of pancreatic sarcoidosis is good. Our case highlights pancreatic sarcoidosis as one of the important differential diagnosis of pancreatic mass lesion. It should be included in the work-up of pancreatic lesion and health professionals should be aware of this idiopathic multisystemic disease.