Hypertensive Emergency Leading to Diagnosis of Metastatic Pancreatic Cancer

Abstract

Pancreatic cancer (PC) is associated with poor survival rate. The overall 5-year survival is less than 5%. We report a case of a patient who presented with uncontrolled blood pressure and acute kidney injury. By following a systematic approach, she was diagnosed with metastatic PC. A 63-y.o. female with PMH of HTN and hypothyroidism presented with frontal headache and blurry vision for 2 days. Patient was previously in her usual state of health. On arrival to ER, her physical exam was normal except for blood pressure of 219/105 that improved with IV labetalol and remained stable afterwards. Her blood work was normal except for acute kidney injury with creatinine of 3.8 mg/dL. Work up including CT head and MRI brain was negative. Due to elevated creatinine, US abdomen was done that showed significant bilateral hydronephrosis, more on the right side. CT abdomen confirmed bilateral hydroureteronephrosis, pyelocaliectasis without evidence of an obstructing renal stone and a 7.3 x 4.7 cm soft tissue mass within the splenic hilum with mild pancreatic ductal dilatation (IMG1). Patient underwent bilateral nephrostomy tubes with subsequent improvement of her creatinine to 1.2 mg/dL. MRI abdomen with and without contrast was then done to clarify CT findings, showing a 10.5 x 6.3 cm mass in the tail of the pancreas that abuts the splenic hilum and left kidney (IMG2). Malignant process was suspected so patient underwent EUS that showed a mass in the pancreatic body and pancreatic tail with endosonographic appearance consistent with adenocarcinoma that was staged T3 N0 Mx by endosonographic criteria. Cytology confirmed adenocarcimoa of the pancreas. CT chest was done to complete staging showing multiple bilateral lung nodules. CA19-9 was > 700,000 (N <34 U/mL). PC is an aggressive disease and ranks fourth in cancer-related mortality in USA. Because of the delayed presentation of definitive signs and symptoms of PC and the anatomic location of the pancreas, pancreatic tumors are rarely detected early, typically in an advanced stage by the time of presentation. This case is unique as a systematic approach to a patient presenting with hypertensive emergency, led to diagnosis of metastatic PC. It also highlights the rare initial presentation of PC with acute kidney injury secondary to bilateral hydronephrosis. Proposed mechanism of hydronephrosis is bilateral ureteral metastasis from PC that is exceedingly rare and only few cases are reported in the literature.1239_A.tif Figure 1: CT abdomen without contrast Yellow arrows outlining splenic hilar mass Red arrows pointing at hydronephrosis1239_B.tif Figure 2: MRI revealing splenic hilar mass of pancreatic origin