Pancreatic Sarcoidosis Diagnosed by EUS with FNA

Abstract

We present a case of pancreatic sarcoidosis in a patient with painless jaundice and a pancreatic mass. Definitive diagnosis was obtained by EUS with fine-needle aspiration (FNA) for sarcoidosis, thereby avoiding surgical exploration. A 39 year-old African American male with a history of neurosarcoidosis developed jaundice and presented for evaluation. The patient denied abdominal pain, nausea, vomiting, and fever/chills. He noted a 100 lb weight loss over the last year that was partly intentional. Furthermore, the patient admitted to pruritis, clay-colored stools, and dark urine color. Initial laboratory evaluation revealed a total bilirubin 12.3, direct bilirubin 10.3, alkaline phosphatase 311, AST 86, ALT 30, but normal pancreatic enzymes. MRI revealed a 3.7 cm × 4.8 cm × 4.9 cm mass in head of pancreas with peripancreatic lymph node enlargement (Fig. 1). Moderate intrahepatic biliary duct dilatation was noted as well as common bile duct (CBD) and pancreatic duct dilatation. A Ca 19–9 level was elevated at 367 U/ml. An EUS was performed with FNA. An enlarged hypoechoic pancreatic head pancreas without discrete pancreatic mass was noted. Peripancreatic lymphadenopathy was observed. A #22 gauge needle was used to obtain an FNA of both the pancreatic head and surrounding lymph nodes. An ERCP was then performed which revealed a 3 cm stricture in the distal CBD. A sphincterotomy was performed followed by placement of a 10 French/9 cm CBD stent with resultant bile flow. Biopsy of the pancreatic head and surrounding lymph nodes was negative for malignant tumor cells. Non-caseating granulomas were identified in both the pancreatic head and LAD. Flow cytometry and bile duct brushing were both negative. The patient was subsequently started on steroids for treatment of his sarcoidosis after rheumatology consultation. Sarcoidosis involving the pancreas is rare and is often diagnosed incidentally following surgical resection of a periampullary pancreatic mass. We describe a case of pancreatic sarcoidosis presenting as a pancreatic mass concerning for malignancy and diagnosed by EUS with FNA. The use of EUS in obtaining a definitive tissue diagnosis prevented surgical exploration.