Hypodense Mass Research Articles

Endoscopic Management of a Large Tornwaldt Cyst: A Case Report

ABSTRACT
 Objective: To report successful marsupialization of a large Tornwaldt cyst using combined transnasal and transoral endoscopic surgery in a 7-year-old girl who presented with nasal obstruction.
 Methods:Design: Case ReportSetting: Tertiary Government Training HospitalPatient: One
 Result: A 7-year-old girl presented with an 11-month history of recurrent yellowish nasal discharge gradually associated with nasal obstruction. Examination revealed a large, well encapsulated, broad-based cystic mass in the nasopharynx immediately adjacent to the posterior choanae, continuing posterior to the soft palate (pushing the uvula anteriorly) and extending inferiorly to the epiglottic area. Computerized Tomography (CT) demonstrated a well-circumscribed, midline hypodense mass with fluid attenuation obstructing the nasopharyngeal area extending inferiorly to the oropharyngeal area. Endoscopic marsupialization via transnasal and transoral approach was successful, and a respiratory epithelium-lined cyst consistent with a Tornwaldt cyst was confirmed by histopathologic examination
 Conclusion: Combined transnasal and transoral endoscopic marsupialization is possible a for a large symptomatic Tornwaldt cyst in a pediatric patient with relatively smaller and complex nasal cavities.

Intravascular Fasciitis of the Femoral Vein Mimicking Thrombosis and Sarcoma

A 42 year old woman presented with swelling and pain of the left lower limb. Laboratory tests were unremarkable. Ultrasonography indicated left common femoral venous “thrombosis”. Venography revealed segmental vein occlusion. Computed tomography revealed an enlarged femoral vein with a hypodense mass. Magnetic resonance showed a 2.7 × 1.4 × 1.5 cm well enhanced mass (A, arrow). Intra-operative histopathological examination reported spindle cell sarcoma. Complete resection and reconstruction with great saphenous vein was performed. However, intravascular fasciitis was considered based on immunohistochemistry (smooth muscle actin positive but desmin negative), and was confirmed by fluorescence in situ hybridisation for ubiquitin specific protease 6 rearrangement (B, separation of green and red signals in blue nuclei).Image 1

A rare cause of bilateral exophthalmos: about one case with a sphenoid mucocele

Background: Mucocele is a benign cystic pseudo-tumor that develops within the sinus cavities. The most frequent locations are frontal and frontoethmoidal. The sphenoidal forms are rare. We report a case of sphenoidal mucocele revealed by bilateral exophthalmos. Methods and results: We report the case of a 14 year old male patient, without any particular pathological history, referred by his ophthalmologist for bilateral nasal obstruction, bilateral exophthalmos and visual acuity decrease evolving since one year. The ENT examination found a large, renitrant mass, filling the entire right nasal cavity. This mass pushed the nasal septum to the left. The CT scan showed a large sphenoidal, hypodense mass evoking a mucocele. The patient underwent endonasal marsupialization by endoscopic guidance. Conclusions: Sphenoidal mucocele is a rare cause of bilateral exophthalmos. The diagnosis can be misplaced when the signs are overt extra-sinus. Hence the interest of CT in order to eliminate other differential dignostics.

S1448 Solid Pseudopapillary Neoplasm of Pancreas: A Rare Pancreatic Malignancy

INTRODUCTION: Solid pseudopapillary neoplasm of pancreas (SPN) is one of the rarest types of pancreatic tumors, <2% of all pancreatic malignancies, also known as a Hamoudi or Frantz tumor. SPNs usually presents asymptomatically in females in the third decade of life and found incidentally on radiological imaging. CASE DESCRIPTION/METHODS: Here, we present three proven SPN cases by histology. Case 1: A 42-year-old Hispanic female with no past medical history who presented with 1-day history of cough, incidentally found to have a 3 cm hypodense lesion in the pancreatic body on CT scan. Endoscopic ultrasound (EUS) with biopsy was performed and immunohistochemical (IHC) studies found tumor cells to be positive for B-catenin, progesterone receptor and neuron specific enolase, consistent with a diagnosis of SPN. Case 2: A 48-year-old African American female with a past medical history of GERD presented with intermittent right upper quadrant abdominal pain. CT demonstrated a large solid, periportal hepatic mass (19 × 17 × 19 cm) as well as a multi-cystic mass (14 × 7 × 10 cm) arising from the distal pancreatic tail. Exploratory laparotomy was performed and pathology showed a uniform population of small cells with pseudopapillary structures with IHC profile supporting the diagnosis of metastatic SPN. Case 3: A 31-year-old Hispanic female with no significant past medical history presented with 2 months history of post-prandial epigastric abdominal pain found to have a hypodense mass (4 × 4 cm) in the distal pancreatic tail. Surgical resection was performed. Pathology findings of neoplastic tumor cells with occasional groves, collections of histiocytes, and hyaline globules with positive IHC staining for vimentin, B-catenin and progesterone receptor, consistent with diagnosis of SPN. DISCUSSION: On imaging, SPN tumors typically appear as a well-defined mass, with a thick, enhancing capsule, often with peripheral or central calcification. Although most often solid, they can demonstrate variable internal hemorrhagic or cystic components. EUS is the modality of choice for further imaging and definitive diagnosis, as biopsy can be performed. Here, we describe three cases including a unique and rare case of metastatic SPN. Clinicians should be aware of this relatively rare pancreatic lesion as its presentation may be insidious and early imaging is key. Once diagnosed, physicians should pursue multidisciplinary discussions with early surgical management even in metastatic disease, as outcomes are excellent with a favorable prognosis.Figure 1.: MR Imaging - SPN.Figure 2.: Endoscopic US - SPN.Figure 3.: Histopathology - SPN.

S1455 A Rare Case of Poorly Differentiated Metastatic Extra-Pulmonary Neuroendocrine Tumor in an HIV Patient

INTRODUCTION: HIV infected individuals have an increased risk of malignancies such as Kaposi sarcoma, primary central nervous system lymphoma, non-Hodgkin lymphom, and cervical cancer. The incidence of non-AIDSdefining tumors such as Neuroendocrine Tumor (NET) has not been well reported in the literature. Majority of NETs occur in the gastrointestinal tract (almost 68%) and bronchopulmonary tree (about 25%). Of the GI NETs, most are in the small intestine with less than 1% of pancreatic origin. We present an HIV patient with primary pancreatic NET with metastasis to the liver. CASE DESCRIPTION/METHODS: A 56-year-old African American male with history of HIV currently on antiretrovirals presented with complaints of non-radiating chest pain, shortness of breath, back pain, dizziness, night sweats, nausea, constipation, and recent weight loss. Patient is a current non-smoker with 30 pack year history, no recent travel or sick contacts. Initial workup, including CBC, CMP, EKG, and chest x-ray on admission were unremarkable. Physical exam and vital signs were within normal limits; however, due to the presenting symptoms, CTA of the chest was obtained revealing an incidental finding of a hypodense soft tissue mass highly suspicious for lymphoma. Follow up CT Abdomen and Pelvis with contrast revealed retroperitoneal and periportal lymphadenopathy along with a 3.7 cm Liver mass, suggestive of lymphoma with soft tissue metastasis. In view of these findings the primary working diagnosis was HIV associated lymphoma. However, CT guided liver and lymph node biopsy pathology favored metastatic large cell neuroendocrine carcinoma, most probable primary in pancreas. DISCUSSION: Even though there are malignancies commonly associated with HIV and AIDS, it is important to keep a broad differential when working up a patient with HIV. The incidence of ADC decreased 2-3 folds since 1998 while NADC increased in incidence but no variance of standardized in the same time frame. This has been attributed to the introduction of combination antiretroviral therapies that increased HIV patients life expectancy and allowing them to be at the same risk of developing age-related cancers as the general population. NET in HIV positive patients in sites other than lungs and skin has not been well characterized. Previous study has shown a correlation between Merkel Cell carcinoma and concurrent HIV infection, and it is unclear if our pancreatic cancer is sporatic or associated with HIV infection.

S1481 Isolated Pancreatic Mass: A Unique Presentation of Tuberculosis

INTRODUCTION: Malignancy is often the culprit after discovery of an isolated pancreatic mass. It is important to consider other etiologies including infectious etiologies such as tuberculosis. CASE DESCRIPTION/METHODS: A 28 year old Vietnamese immigrant with no significant medical history presented with intermittent nausea and epigastric pain for several years that acutely worsened over two days. She reported the pain radiated to her back and was exacerbated by spicy foods. She denied any fevers, weight loss, or jaundice. Lipase and liver function tests were normal. CT imaging of the abdomen showed a 4cm heterogeneous hypodense pancreatic lesion but was otherwise normal (Figure 1a). EUS was notable for hypoechoic mass in the pancreatic head with irregular margins and no vascular invasion (Figure 1b). Fine needle aspiration cytology revealed granulomatous inflammation with extensive necrosis and negative AFB/GMS stains. Quantiferon Gold testing was positive and HIV testing was negative. Chest x-ray was normal. She had no prior history of tuberculosis and no known high risk exposures. Her immigration medical testing in 2012 was reportedly normal. In light of the pathologic and serologic findings, the patient was treated for isolated pancreatic tuberculosis with RIPE therapy. Her gastrointestinal symptoms resolved on therapy and follow-up CT imaging 6 months after completion of antibiotics showed complete resolution of the pancreatic mass. DISCUSSION: The gastrointestinal tract is the 6th most common site of extrapulmonary tuberculosis and is seen in only about 5% of all tuberculosis cases; the ileocecal region is involved in the majority of cases. Isolated pancreatic tuberculosis is considered an extremely rare entity since pancreatic enzymes usually destroy any intrusive pathogens. These patients are typically immunocompromised. Abdominal pain and jaundice are well-known symptoms but weight loss and fevers and also commonly seen. Imaging will show a hypodense mass without any biliary ductal dilation or vascular invasion. EUS with fine needle aspiration is done for initial investigation while excisional biopsy is the most accurate diagnostic tool. Patients tend to respond very well to antituberculosis therapy. We present a unique case of an immunocompetent patient with dyspeptic symptoms who had no prior personal history of tuberculosis or known high risk exposure and was found to have isolated pancreatic tuberculosis.Figure 1.: Figure 1a. Initial CT abdomen/pelvis showing a multilobulated heterogeneous pancreatic mass (red circle).Figure 2.: b. EUS findings notable for a 4 cm × 4 cm pancreatic head mass with irregular outer margins.

Intracardiac Thrombus in Sinus Rhythm: A Case of Missed Cardiac Amyloidosis

Intracardiac thrombus in patients with amyloid cardiomyopathy in sinus rhythm is a rare phenomenon, and no guidelines currently exist regarding screening, diagnosis, or management. We describe a case of a 59 year-old female who presented to the hospital with dyspnea on exertion, orthopnea, pedal edema, and weight gain. She had a one year history of heart failure with preserved ejection fraction, treated with metoprolol, bumetanide, and metolazone, and three month history of AL amyloidosis, treated with Bortezomib and Dexamethasone. Upon admission, labs showed leukocytosis, thrombocytosis, and elevated troponin and BNP. Electrocardiogram revealed sinus rhythm with left atrial enlargement. CT chest angiography showed pulmonary edema and a hypodense mass in the right atrium/atrial appendage. Cardiac magnetic resonance imaging demonstrated moderate concentric hypertrophy, elevated native T1 (1126 ms), diffuse late gadolinium enhancement, and elevated ECV (52%) consistent with cardiac amyloidosis. A right atrial mass consistent with a thrombus was visualized. Intracardiac thrombus was treated with intravenous heparin, which was transitioned to warfarin. Volume overload secondary to AL-cardiac amyloidosis was managed with diuresis. She was discharged home with hospice and passed approximately one month later. This case illustrates a missed diagnosis of cardiac involvement of systemic AL amyloidosis, ultimately resulting in death within nearly one year from initial diagnosis of heart failure. It also explores the etiology, diagnosis, and treatment of an intracardiac thrombus in patients with cardiac amyloidosis in sinus rhythm. Therefore, this case demonstrates the need for evidence-based guidelines regarding stratification of thrombotic risk and serial monitoring in patients with cardiac amyloidosis without arrythmia. Furthermore, it exemplifies the importance of high suspicion for cardiac amyloidosis to guide early diagnosis and management of patients with cardiac involvement of systemic amyloidosis, in addition to screening and monitoring of associated comorbidities, to improve prognosis and overall survival.

A case report of rare, giant adrenal myelolipoma

Giant adrenal myelolipoma is a rare entity. It becomes evident due to symptoms of dragging sensation and discomfort or pain. We report hereby a rare case report giant adrenal myelolipoma. A 51-year-old female presented with pain in the right upper abdomen, dull aching, non radiating, no aggravating, or relieving factor present. It was associated with a lump in the right upper abdomen. Computed tomography of the abdomen suggested a 20 cm × 18 cm well encapsulated, hypodense mass, arising from right suprarenal gland inferior to the right lobe of the liver, pushing right kidney inferiorly, and inferior vena cava medially. It showed predominantly fat component and a small area of soft-tissue attenuation with maintained adjacent fat planes, suggestive of right adrenal myelolipoma. After preoperative stabilization, excision of right adrenal myelolipoma was done under general anesthesia and epidural anesthesia.

ADULT RHABDOMYOMA OF THE ORAL CAVITY

This report describes a case of adult rhabdomyoma (AR) in the oral cavity. A 47-year-old male was referred for diagnosis of a painless lesion located in floor of the mouth, with 2 years of duration. Intra-orally, the lesion appeared as a large, well-delimited swelling mass measuring about 5.0 cm, projecting the tongue superiorly and posteriorly. On computerized tomography examination, there was a well-delimited, solid, hypodense mass. The main hypothesis of diagnosis was a salivary gland tumor. The patient was submitted to surgical excision. Microscopically, the nodule was composed by large polygonal cells with well-defined borders, which exhibited abundant, eosinophilic, and granular cytoplasm. Cross-striation in the cytoplasm was also observed, and there were no atypia or mitoses. The cells were positive for muscle-specific actin, desmin, and α-sarcomeric actin. Calponin, h-caldesmon, and myogenin were negative. Based on these features, the diagnosis of AR was established. No recurrence was observed after 24 months.

CERVICAL TUBERCULOUS LYMPHADENITIS IN A CHILD: A CASE REPORT

Tuberculosis (TB) is an infectious disease primarily affecting the lungs, and the most common manifestation of extra-pulmonary tuberculosis is tuberculous lymphadenitis. A healthy 6-year-old female presented with a complaint of an asymptomatic swelling on the right side of her neck with gradual growth within 20 weeks. Extra-oral examination showed diffuse submandibular lymphadenopathy, erythematous aspect, painful and consistent under palpation and with central fluctuation. Intra-orally, the patient presented with multiple carious lesions. The patient’s CT showed a homogeneous, well-defined, hypodense mass in the submandibular region measuring 2.39 × 2.01 cm leading to the following hypotheses: dentoalveolar abscess, dermoid cyst, and pleomorphic adenoma. The patient was referred to a total lesion exeresis under general anesthesia. Histopathologic results showed lymphoid tissue presenting dense lymphocytes infiltrate, caseous necrosis, and giant multinucleated cells (Langhans type), leading to a final diagnosis of cervical tuberculous lymphadenitis. The patient was immediately transferred to start anti-TB treatment, undergo a chest radiography, and have an HIV test.

Mediastinal epidermoid cyst in an old man with recurrent pneumonia: A case report

Mediastinal epidermoid cyst is a rare condition that is considered as a congenital disorder. Various manifestations from asymptomatic cases to serious symptoms may be found in these patients. However, some cases may be diagnosed incidentally. Here, we report an old man with recurrent pneumonia who demonstrated symptoms of respiratory distress and chest pain. The high resolution computed tomography (HRCT) and subsequent magnetic resonance imaging (MRI) showed a hypodense mass with internal calcification. CT-scan guided transthoracic needle biopsy confirmed diagnosis of mediastinal epidermoid cyst. The mass was resected through open surgery and patient’s symptoms were subsided.

BASAL CELL ADENOMA: A CASE REPORT

Basal cell adenoma is a benign neoplasm of salivary gland with 1% to 2% of tumors of that order. The nomenclature derives from the basaloid appearance of its tumor cells formed by the combination of salivary duct epithelium and myoepithelial cells. The present study aims to report the case of a 70-year-old male leucoderm patient admitted by the department of maxillofacial surgery presenting clinically a tumor lesion in the left buccal region with hardened consistency on palpation, painless, mobile, with 1-year evolution. In the cranial computed tomography with a soft profile window, we observed a hypodense mass image, well delimited and approximately 2 cm in its largest diameter. In view of these characteristics, the diagnostic hypothesis was pleomorphic adenoma. Excisional biopsy was performed with local anesthesia at the outpatient operating room. The specimen was referred for histopathologic analysis, defining diagnosis for basal cell adenoma. The patient is in periodic postoperative follow-up.

Primary Pancreatic Diffuse Large B-Cell Lymphoma Involving the Stomach

Primary pancreatic lymphoma (PPL) is extremely rare, comprising fewer than 1% of non-Hodgkin lymphomas. The most common histological subtype of PPL is diffuse large Bcell lymphoma (DLBCL). A 46-year-old man presented with indigestion, epigastric pain, and weight loss for 2 months. Abdominal computed tomography showed a well-defined hypodense mass located at the pancreas head involving the stomach, as well as enlargement of several mesenteric and perigastric lymph nodes. Histological examination was performed by upper gastrointestinal endoscopy of the stomach and endoscopic ultrasound-guided fine-needle aspiration and biopsy of the pancreatic mass. Histology of the pancreatic mass and the stomach revealed pancreatic DLBCL, involving the stomach. The patient received chemotherapy and is currently in complete remission. We report a rare presentation of DLBCL, appearing as a primary pancreatic tumor involving the stomach, which we presume is the first such report in South Korea.

CT imaging of acute and chronic pyelonephritis: a practical guide for emergency radiologists

Contrast-enhanced CT is not routinely indicated in uncomplicated urinary infections, but it may be necessary in patients with specific risk factors (i.e., diabetes, immunocompromised patients, history of stones, or prior renal surgery) or in patients not responding to antibiotics and in detecting complications of pyelonephritis. CT is the gold standard for imaging assessment of pyelonephritis severity. Imaging appearance of acute pyelonephritis, including focal (i.e., wedge-shaped zones of decreased attenuation or hypodense mass) and diffuse (i.e., global enlargement, poor parenchymal enhancement, lack of excretion of contrast, fat stranding) forms, needs to be differentiated from renal infarction, renal lymphoma, and interstitial nephritis. Chronic pyelonephritis-which appears as focal polar scars with underlying calyceal distortion, global atrophy, and hypertrophy of residual tissue-may mimic at imaging lobar infarcts. This pictorial essay reviews the CT imaging appearance of acute and chronic pyelonephritis, their uncommon subtypes, and their complications, with key features for early diagnosis. Their knowledge is crucial for emergency and abdominal radiologists to avoid misdiagnosis with malignancy and to guide the clinician towards the appropriate medical or surgical treatment.

A Rare Case of Sublingual Gland Hydatid Cyst

Background: Hydatid cyst is a zoonotic disease due to the infection with the larvae of&#x0D; Echinococcus granulosus. The liver and lungs (80%) are the main organs involved and rarely&#x0D; head and neck.&#x0D; Case Presentation: A 47-year-old Iranian man presented to our center complaining of&#x0D; sublingual inflammation for 8 months. Sonography revealed a cystic lesion of 4×5×6 cm within&#x0D; the tongue. CT-scan showed a well-defined and hypodense mass in the floor of the mouth.&#x0D; Cyst resection was performed with the probability of ranula. Pathology was suggestive of&#x0D; hydatid cyst. Further workups revealed liver involvement. Therefore, he was treated with&#x0D; albendazole for 2 months.&#x0D; Conclusion: The hydatid cyst in the head and neck is rare and the involvement of sublingual&#x0D; gland is extremely rare. However, in endemic areas, hydatid cyst should be considered in the&#x0D; differential diagnosis of head and neck masses.

KILLIAN POLYP IN THE MAXILLARY SINUS: A CASE REPORT

The antrochoanal polyp, also called Killian polyp, represents around 4% to 6% of all nasal polyps with a higher incidence in children and young adults. It is a benign lesion that grows from the mucosa of the maxillary sinus and reaches the choana. A 34-year-old male patient attended the surgical service to remove a mesiodens. No noteworthy changes were observed at the intraoral examination. Computed tomography evidenced a well-circumscribed and delimited hypodense mass in the left maxillary sinus. An excisional biopsy was performed, and histopathologic analysis revealed the presence of a loose, edematous connective tissue with thin lines consisting of collagen fibers, congested vessels, and a discrete presence of lymphocytes and plasma cells. Another region exhibited a peduncle composed of connective tissue and the presence of ciliated pseudocolumnar epithelium. The diagnosis of a Killian polyp was established. The patient is under follow-up for 4 months without signs of relapse.

Adult-Onset Cystic Hygroma in the Axilla in a 44-year old Female: A Case Report

This is a case of a 44- year old female presenting with an 18cm x 17cm soft, movable, non-tender mass at the right axilla extending to the lateral aspect of the right breast. Computerized tomographic scan of the chest revealed a lobulated, multi-septated hypodense mass. The patient underwent excision of the right axillary mass and final histopathology revealed cystic lymphangioma. Adult-onset cystic hygroma of the axilla is a rare case, with less than 10 studies documented in PubMed. Total surgical excision remains to be its primary treatment. Key words: Adult-onset cystic hygroma, cystic hygroma, lymphangioma, axilla

1742 A Rare Case of Colorectal Cancer of the Neoesophagus

INTRODUCTION: In the case that follows, we present a case and literature review of oligometastatic intestinal adenocarcinoma originating in a colonic interposition repair of esophageal atresia. Uniquely, the pathology of the tumor was consistent with colonic mucosa which only a few such instances have been reported in literature. CASE DESCRIPTION/METHODS: A 58-year-old female with a past medical history of tetralogy of Fallot (repaired at age 14), esophageal atresia status post esophageal colonic interposition, esophageal and pyloric stenosis, neo-esophageal polyp (found 2 years prior with biopsy showing reactive epithelial atypia), and atrial fibrillation on Coumadin presented to the hospital complaining of fatigue and dyspnea of one week duration. Her family history was significant for colon cancer in her father. Initial lab workup revealed a hemoglobin of 5. She was transfused 3 units of packed red blood cells. Due to severe symptomatic anemia, an upper endoscopy and colonoscopy were performed revealing an ulcerated mass, approximately 50% in circumference in the lower third of the esophagus, as well as moderate pyloric stenosis that prevented passage of the endoscope. The esophageal masswas not amenable to endoscopic excision due to undulations of the cardiac beat, however biopsy demonstrated invasive, moderately differentiated, intestinal-type adenocarcinoma (Figure 1). Given these findings a PET/CT scan was obtained which revealed a 2cm mass in the distal aspect of the interposed colonic segment and a 1.7 × 1.2cm hypodense mass in the medial segment of the left hepatic lobe, consistent with metastasis. She was referred to Cardiothoracic Surgery for tumor resection and Oncology for neoadjuvent chemotherapy. DISCUSSION: Oligiometastatic colorectal cancer or the esophagus is an extremely rare medical condition. Our patient had an initial polyp removed in 2016, that was read as reactive epithelial atypia. More diligent surveillance was likely warranted for her case. This was shown by Lindahl et al in long-term endoscopic follow-ups in patients with this condition. Of the 12 patients observed in the study, a variety of colonic pathology was foundranging from dysplasia, colonic polyp, and aneuploid cells. Given these findings, albeit rare, with one case report citing less than 15 instances, special considerations should be made for close surveillance of these patients. Although no specific treatment guidelines exist for this anomaly, there has been documented success with a curative resection.

1308 An Extraordinary Case of Delayed and Isolated Recurrence of Renal Cell Carcinoma in the Pancreas

INTRODUCTION: Renal cell carcinoma (RCC) is the most common malignancy of the kidney. RCC is curative with nephrectomy followed with post-operative surveillance with computed tomography (CT) or magnetic resonance imaging (MRI). RCC recurrence rarely occurs beyond 5 years. We present a 57-year-old woman 8 years post left nephrectomy due to RCC, who presented with an incidental pancreatic head mass on MRI subsequently confirmed as RCC. CASE DESCRIPTION/METHODS: A 57- year old Caucasian woman with a past medical history of recently diagnosed T1a N0M0 colorectal carcinoma (CRC) status post right hemicolectomy and Grade 2 RCC status post left nephrectomy 8 years prior to presentation, underwent post-surgical surveillance for CRC two months post hemicolectomy. She reported no clinical symptoms. Incidental findings on outside hospital MRI of the abdomen and pelvis with contrast demonstrated a 2.5 cm hypodense mass at the pancreatic head (Figure 1). Metastatic work up for CRC including whole body positron emission tomography was negative. She was referred to our institution for endoscopic ultrasonography with find needle aspiration (EUS-FNA) of the pancreatic mass. Blood test showed normal liver function test and CA 19-9. The EUS showed a 2 cm × 2 cm ill-defined hypoechoic and heterogenous in echotexture mass in the head and neck of the pancreas (Figure 2). A 22-gauge needle with a stylet was used to perform FNA. Immunostains showed neoplastic cells positive for PAX-8 and RCC; immunophenotype consistent with clear cell RCC (Figure 3). She underwent successful central pancreatomy with pancreato-gastrostomy without complications. DISCUSSION: This case is extraordinary as RCC recurred after 8 years following nephrectomy as an isolated pancreatic mass following 5-year surveillance without evidence of recurrence. Up to 93% of recurrence occurs within 5 years post nephrectomy and current guidelines recommend RCC surveillance up to 5 years post nephrectomy. EUS-FNA provided a minimally invasive method of accurately diagnosing metastatic RCC and is an excellent tool for evaluating pancreatic lesions. Reporting such a case should raise the awareness among physicians for delayed recurrence of RCC in sites such as the pancreas and further longitudinal studies should be sought to assess the prolonged surveillance strategies to identify such recurrences.

3194 Sneaky Abscess-Ion: A Pyogenic Liver Abscess Masquerading as the Flu

INTRODUCTION: Pyogenic liver abscess (PLA) is due to leakage of intra-abdominal contents with hepatic spread via the portal circulation. The incidence of PLA is estimated to be 2.3 cases per 100,000 people with higher rates among men than women [1]. We present a case of a 58-year-old male with no abdominal tenderness, risk factors, or recent travel history, who was found to have a 3 cm liver abscess growing Klebsiella Pneumoniae (K.pneumoniae). CASE DESCRIPTION/METHODS: The patient is a 58-year-old African American man with a medical history of HTN and HLD who presented with 3-day history of muscle aches, subjective fevers, and chills. Initially the patient was suspected to have a flu and was treated with fluids and antipyretics. He was noted to have transaminitis (AST/ALT: 202/139), however denied nausea or abdominal pain. An ultrasound demonstrated a complex cystic mass in the right lobe of the liver, and a CT Abd/Pelvis showed a 3.2 × 3.1 × 2.3 cm heterogeneous hypodense mass in segment V. The patient remained febrile with a Tmax of 102 and began to develop severe RUQ on day two of admission. The patient was maintained on Zosyn 3.375g q6h and initial blood cultures grew gram negative rods. Patient tolerated IR drainage of liver abscess yielding 10cc pustular fluid with subsequent resolution of fever. Both blood and liver cultures grew pan-sensitive K.pneumoniae. DISCUSSION: PLA commonly develops as a complication of biliary tract disease in 40% of cases [2]. In the United States, K. pneumoniae is the predominant pathogen causing PLA; isolated in greater than 60% of monomicrobial and polymicrobial PLA [3]. Groups who are susceptible to infection with K. pneumoniae include patients of Asian ethnicity, diabetics, and those with antibiotic use [2]. Our patient did not have any risk factors for PLA; he had minimal medical history and only took amlodipine on presentation. Common symptoms of PLA include fever, right upper quadrant abdominal pain, and rarely jaundice [1]. Our patients' initial presentation was consistent with a flu like prodrome; however, his transaminitis suggested an underlying hepatic process. While a PLA was unlikely on admission, worsening sepsis and new abdominal pain elucidated the diagnosis. K. pneumoniae PLA can lead to disseminated infections including meningitis; the identification and drainage of an abscess early in the hospital course can alter a patients' mortality. While PLA is rare, it should still remain on the differential diagnosis for septic patients.