Malakoplakia of the Pancreas and Colon in an Immunocompetent Host

Abstract

Introduction: Malakoplakia is an uncommon inflammatory condition usually associated with an underlying immunodeficiency, gram negative infection, or malignancy. Most cases are of genitourinary etiology. We describe a case of malakoplakia with simultaneous presentation in the pancreas and colon in an immunocompetent host. Case Report: A 69-year-old male presented to his primary care provider for evaluation of fatigue, 20-pound weight loss, and early satiety. Physical exam was significant for a cachectic appearing male, with a benign abdominal exam. Fecal occult blood test was positive. Laboratory investigation revealed a Hgb of 9.4 g/dL, transferrin saturation 8%, and a ferritin of 39.5 ng/mL. Other labs included a WBC count of 6.2 K/uL (with a normal differential), platelet count 263 K/uL, and INR of 1.74. LFTs were within reference range. HIV was negative. Due to his profound anemia, he was referred for colonoscopy which was significant for an 8-mm nodular submucosal collection of macrophages consistent with malakoplakia. Upper endoscopy was unremarkable. A computed tomography scan of his abdomen demonstrated a 5.8 x 5.2 cm pancreatic head mass. An endoscopic ultrasound confirmed this finding in the setting of an otherwise normal pancreatic parenchyma and pancreatic duct. Fine needle aspirate of the pancreatic head mass was significant for Michaelis-Gutmann bodies. Colon and pancreas specimens were negative for bacteria or malignancy. The patient is currently undergoing empiric antibiotic treatment and is doing well. Discussion: Malakoplakia is an uncommon form of chronic inflammation with usual involvement within the genitourinary tract. Other involved organ systems include the gastrointestinal tract, integumentary system, respiratory tract, central nervous system, HPA axis, and lymphatic system. The Michaelis-Gutmann body is pathgnomic, being described as a phagolysome encrusted with calcium and iron salts. The etiology of Michaelis-Gutmann bodies are thought to be an abnormal response to incompletely digested bacterial fragments and hence has been associated with chronic bacterial infections. Most cases of colonic malakoplakia are associated with colonic adenocarcinoma. Cases of malakoplakia of the pancreas are limited and are usually associated with pancreatic adenocarcinoma. Our case report is the first to our knowledge of a patient presenting with concomitant malakoplakia of the colon and pancreas outside the setting of an immunocompromised state or malignancy. This case highlights the fact that not all cases of iron deficiency anemia are “colon cancer until proven otherwise” and vigilance for zebras should always be present in the clinician’s mind.