Pancreatic Involvement Research Articles

Acquired Thrombotic Thrombocytopenic Purpura and Acute Pancreatitis: Variable and Reciprocal Pathophysiologic Relationships

INTRODUCTIONAcquired thrombotic thrombocytopenic purpura (TTP) is an aggressive thrombotic microangiopathy (TMA). Central to the pathophysiology is loss of ADAMTS 13 activity, due to inhibitors in the acquired form, allowing circulating ulVWF multimers to activate platelets and produce organ damage from microvascular thromboses. Autopsy studies find frequent pancreatic involvement, but clinically evident acute pancreatitis (AP) is infrequently reported. The relationship of TTP and AP may be variable and complex, with either capable of precipitating, exacerbating or mimicking the other. More so than other organ systems, the pancreas has immense potential for cytokine production and proteolytic enzyme release. This characteristic may contribute to the reciprocal fueling, and thus severity, of TTP in association with pancreatitis.METHODSWe generated a descriptive, retrospective case series, querying the Methodist Environmental for Translational Enhancement and Outcomes Research database, a system that integrates Houston Methodist Hospital patient data into a single, comprehensive warehouse. We included all patients in whom TTP and AP were diagnosed during the same hospitalization between 2006 and 2016. Baseline demographics, laboratory values, time between onset of TTP and AP, complications, treatment, as well as short term morbidity and mortality were analyzed.RESULTSTwelve patients were identified as having TTP and AP in the same hospitalization. Demographics, onset intervals, and laboratory values of all patients are summarized in Table 1. Four patients had likely TTP induced AP with time to AP onset between 3 to 28 days, while eight patients had concurrent TTP and AP at initial presentation. All patients had elevated LDH levels with a range of 1575 U/L to 28,342 U/L and decreased platelet counts with a range of 5 k/µL to 59 k/µL. In the seven cases where ADAMTS13 measurements were performed prior to plasma exchenge (PEX), levels were below 5%. With the exception of case 5 in whom mild disseminated intravascular coagulation may have played a role in addition to TTP, no alternative etiologies were identified for the induction of the AP or the TMA.Gastrointestinal (GI) symptoms were observed in 91% of the patients, with severe cases exhibiting ischemic colitis and GI bleeds. Eighty-one percent experienced neurological symptoms, of which 80% were considered major (coma, stroke seizures, or transient focal abnormalities) and the remaining minor (transient headache or confusion). Occurring more often than in TTP patient without AP, significant renal manifestations were seen in 81% (44% progressing to renal failure requiring dialysis), and acute coronary syndromes were experienced by 50%. All patient received fresh frozen plasma, PEX, and glucocorticoids for their TTP. However, 67% of the patients had refractory TTP, of which two thirds required the addition of rituximab. With the exception of two patients who expired secondary to cardiac arrests, all others achieved normalization of their platelets by discharge. Details of the organ involvements, treatments, and complications are summarized in Table 2.CONCLUSIONWe describe twelve patients with clinically evident acute pancreatitis in association with TTP. Compared to the severely ADAMTS13 deficient (<10%) patients reported in other studies, our patients suffered significantly worse organ involvement (George, 2010). Pancreatic cytokine release observed in other studies may have contributed to ADAMTS13 depletion, contributing to the phenotypic severity (Reiter et al, 2003; Bernardo et al, 2004; Mannucci et al, 2004; Swisher et al, 2007; Morioka et al, 2008). A review of literature also revealed the role of pancreatitis in nitric oxide depletion and complement activation, which may augment micro-thrombi formation and fuel TTP propagation. Whereas the relationship between TTP and other organ systems may be one of cause and effect, the relationship between AP and TTP may be one of reciprocal fueling. As such, early appreciation and treatment of pancreatitis might significantly decrease the severity of TTP and improve patient outcomes. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Pancreatic Damage and Radiological Changes in Patients With COVID-19.

Background and objectiveThe novel coronavirus disease 2019 (COVID-19) primarily affects the lungs. However, others organs are also affected in varying degrees. We aimed to investigate the changes in pancreatic density on CT and its correlation with amylase/lipase values in patients diagnosed with COVID-19.Materials and methodsRadiological changes using non-contrast CT and amylase/lipase values were evaluated retrospectively in patients admitted to the pandemic clinic. The patients were classified into two groups: [polymerase chain reaction (PCR)-positive and PCR-negative]. The correlation and difference between the data were evaluated statistically.ResultsThere was no significant difference with respect to age and gender between the two groups (PCR-positive and PCR-negative). There was a significant difference in the head, neck, trunk, and tail of the pancreas and mean density values, but no statistically significant difference in amylase and lipase values between the two groups. No significant correlation was found using Spearman’s correlation test.ConclusionBased on our findings, pancreatic involvement and severe necrotizing pancreatitis can be seen in COVID-19 patients. Pancreatic involvement is more common in patients with severe disease. Patients with gastrointestinal complaints should be evaluated for pancreatitis and their amylase/lipase values should be assessed. We believe that decreased pancreatic density on CT scans can be an early sign of pancreatitis.

Pancreatic Disorders in Children with Inflammatory Bowel Disease.

Background and Objectives: Inflammatory bowel disease (IBD) is a chronic condition and mainly affects the intestines, however, the involvement of the other organs of the gastrointestinal tract (upper part, pancreas, and liver) have been observed. The coexistence of IBD with pancreatic pathology is rare, however, it has been diagnosed more frequently during recent years in the pediatric population. This article reviews the current literature on the most common pancreatic diseases associated with IBD in the pediatric population and their relationship with IBD activity and treatment. Materials and Methods: We performed a systematic review of data from published studies on pancreatic disorders, also reported as extraintestinal manifestations (EIMs), among children with IBD. We searched PubMed and Web of Science to identify eligible studies published prior to 25 April 2020. Results: Forty-four papers were chosen for analysis after a detailed inspection, which aimed to keep only the research studies (case control studies and cohort studies) or case reports on children and only those which were written in English. The manifestations of IBD-associated pancreatic disorders range from asymptomatic increase in pancreatic enzymes activity to severe disease such as acute pancreatitis. Acute pancreatitis (AP) induced by drugs, mainly thiopurine, seems to be the most- often-reported pancreatic disease associated with IBD in children. AP associated with other than drug etiologies, and chronic pancreatitis (CP), are rarely observed in the course of pediatric IBD. The pancreatic involvement can be strictly related to the activity of IBD and can also precede the diagnosis of IBD in some pediatric patients. The course of AP is mild in most cases and may occasionally lead to the development of CP, mainly in cases with a genetic predisposition. Conclusions: The involvement of the pancreas in the course of IBD may be considered as an EIM or a separate co-morbid disease, but it can also be a side effect of IBD therapy, therefore a differential diagnosis should always be performed. As the number of IBD incidences with concomitant pancreatic diseases is constantly increasing in the pediatric population, it is important to include pancreatic enzymes level measurement in the workup of IBD.

Patients With Coronavirus Disease 2019 Interstitial Pneumonia Exhibit Pancreatic Hyperenzymemia and Not Acute Pancreatitis.

ObjectivesGastrointestinal manifestations of coronavirus disease 19 (COVID-19) have been well established, but pancreatic involvement is under debate. Our aims were to evaluate the presence of acute pancreatitis in COVID-19 patients and to assess the frequency of pancreatic hyperenzymemia.MethodsFrom April 1, 2020, to April 30, 2020, 110 consecutive patients (69 males, 41 females; mean age, 63.0 years; range, 24–93 years) met these criteria and were enrolled in the study. The clinical data and serum activity of pancreatic amylase and lipase were assayed in all patients using commercially available kits.ResultsNone of the patients studied developed clinical signs or morphological alterations compatible with acute pancreatitis. However, it was found that 24.5% of the patients had amylase values above 53 IU/L and 16.4% had lipase values above 300 IU/L. Only 1 patient (0.9%) had both amylase and lipase values in excess of 3-fold the upper normal limit without clinical signs of pancreatitis.ConclusionsThe presence of pancreatic hyperenzymemia in a patient with COVID-19 requires the management of these patients be guided by clinical evaluation and not merely by evaluation of the biochemical results.

Pancreatic involvement in murine antibody‐mediated transfusion‐related acute lung injury?

Pancreatic involvement in murine antibody‐mediated transfusion‐related acute lung injury?

Invited Commentary: Infiltrative Growth Pattern in Renal Malignancy-A Clue to Diagnosis and Prognosis.

Invited Commentary: Infiltrative Growth Pattern in Renal Malignancy-A Clue to Diagnosis and Prognosis.

Successful nonoperative management by endoscopic and percutaneous drainage for penetrating pancreatic duct injury: a case report

BackgroundPancreatic trauma is a rare condition with a wide presentation, ranging from hematoma or laceration without main pancreatic duct involvement, to massive destruction of the pancreatic head. The optimal diagnosis of pancreatic trauma and its management approaches are still under debate. The East Association of Surgery for Trauma (EAST) guidelines recommend operative management for high-grade pancreatic trauma; however, several reports have reported successful outcomes with nonoperative management (NOM) for grade III/IV pancreatic injuries. Herein, we report a case of grade IV pancreatic injury that was nonoperatively managed through endoscopic and percutaneous drainage.Case presentationA 47-year-old Japanese man was stabbed in the back with a knife; upon blood examination, both serum amylase and lipase levels were within normal limits. Contrast-enhanced computed tomography (CT) showed extravasation of the contrast medium around the pancreatic head and a hematoma behind the pancreas. Abdominal arterial angiography revealed a pseudo aneurysm in the inferior pancreatoduodenal artery, as well as extravasation of the contrast medium in that artery; coil embolization was thus performed. On day 12, CT revealed a wedge-shaped, low-density area in the pancreatic head, as well as consecutive pseudocysts behind the pancreas; thereafter, percutaneous drainage was performed via the stab wound. On day 22, contrast radiography through the percutaneous drain revealed the proximal and distal parts of the main pancreatic duct. The injury was thus diagnosed as a grade IV pancreatic injury based on the American Association for the Surgery of Trauma guidelines. On day 26, an endoscopic nasopancreatic drainage tube was inserted across the disruption; on day 38, contrast-enhanced CT showed a marked reduction in the fluid collection. Finally, on day 61, the patient was discharged.ConclusionsAlthough the EAST guidelines recommend operative treatment for high-grade pancreatic trauma, NOM with appropriate drainage by endoscopic and/or percutaneous approaches may be a promising treatment for grade III or IV trauma.

Differential diagnosis between pancreatic involvement in IgG4-related disease and pancreatic cancer

IgG4-related disease is a systemic disorder characterised by diffuse or tumoural inflammatory lesions. It can mimic pancreatic cancer, leading to increased rates of morbidity and mortality in patients as well as errors in diagnosis and treatment. The aim of this review is to take a differential diagnostic approach to these two entities using epidemiology, clinical and laboratory findings, imaging and histopathology. La enfermedad relacionada con IgG4 es un trastorno sistémico caracterizado por lesiones inflamatorias difusas o tumorales. Puede simular cáncer pancreático, condicionando un aumento en la morbimortalidad de los pacientes y errores diagnósticos y terapéuticos. El objetivo de esta revisión es realizar una aproximación diagnóstica diferencial de estas dos entidades, desde el punto de vista epidemiológico, clínico, analítico, imagenológico e histopatológico.

Genotype-Phenotype Correlation in Fibrous Dysplasia/McCune-Albright Syndrome

Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare bone and endocrine disorder resulting in fractures, pain, and disability. There are no targeted or effective therapies to alter the disease course. Disease arises from somatic gain-of-function variants at the R201 codon in GNAS, replacing arginine by either cysteine or histidine. The relative pathogenicity of these variants is not fully understood. This work aimed 1) to determine whether the most common GNAS variants (R201C and R201H) are associated with a specific clinical phenotype, and 2) to determine the prevalence of the most common GNAS variants in a large patient cohort. This retrospective cross-sectional analysis measured the correlation between genotype and phenotype characterized by clinical, biochemical, and radiographic data. Sixty-one individuals were genotyped using DNA extracted from tissue or circulating cell-free DNA. Twenty-two patients (36.1%) had the R201C variant, and 39 (63.9%) had the R201H variant. FD skeletal disease burden, hypophosphatemia prevalence, fracture incidence, and ambulation status were similar between the 2 groups. There was no difference in the prevalence of endocrinopathies, ultrasonographic gonadal or thyroid abnormalities, or pancreatic involvement. There was a nonsignificant association of cancer with the R201H variant. There is no clear genotype-phenotype correlation in patients with the most common FD/MAS pathogenic variants. The predominance of the R201H variant observed in our cohort and reported in the literature indicates it is likely responsible for a larger burden of disease in the overall population of patients with FD/MAS, which may have important implications for the future development of targeted therapies.

Immunoglobulin G4 Related-Disease: A Rare Presentation With Secondary Hypereosinophilic Syndrome and Eosinophilic Ascites

Immunoglobulin G4 related-disease (IgG4-RD) is a multisystemic immune-mediated fibroinflammatory disease, with a strong predilection for salivary and lacrimal glands, pancreas, biliary tree, lungs, kidneys, aorta, and retroperitoneum. In the case of pancreatic involvement, it manifests as autoimmune pancreatitis. Patients with IgG4-RD usually have mild to moderate eosinophilia in the peripheral blood, however, they may present a secondary hypereosinophilic syndrome (HES). Although there are cases described with severe eosinophilia (> 5,000/µL), the 2019 American College of Rheumatology/European League Against Rheumatism classification criteria for IgG4-RD considers peripheral eosinophilia above 3,000/µL as an exclusion criterion, although stating that assessment for the presence of exclusion criteria should be individualized depending on a patient’s clinical scenario. Here, we describe the clinical case of a 30-year-old woman who presented with chronic diarrhea and abdominal pain. The diagnostic workup revealed eosinophilic ascites, severe peripheral blood eosinophilia (> 5,000/µL), IgG4 elevation (> 2 × upper normal limit), and also diffuse swelling in the body and pancreatic tail (computed tomography (CT) scan). There was a prompt response to corticosteroid therapy with clinical resolution and continued remission under therapy. The patient was diagnosed with IgG4-RD with secondary HES, explaining the gastrointestinal tract and peritoneum damage in the form of enterocolitis and ascites. Exclusion of alternative diagnosis was made. J Med Cases. 2021;12(3):107-111 doi: https://doi.org/10.14740/jmc3634

Pancreatite posterior a infecção por SARS-CoV-2 em paciente pediátrico indígena da tribo Paranapuã

OBJECTIVE: To hypothesize a correlation between previous infection by SARS-Cov-2 and acute pancreatitis due to the inflammatory process caused by the virus in an indigenous pediatric patient. CASE REPORT: A 7-year-old female indigenous patient, from the Paranapua tribe, with a history of contact with community with COVID-19 infected, presenting with acute pancreatitis of unknown etiology even after laboratory and imaging investigation, presenting with pulmonary involvement and IgG positive for SARS-CoV-2. COMMENTS: At the threshold of the COVID-19 pandemic, there was an increase in the involvement of various organs and systems, especially in pediatric patients, intriguing the appearance of inflammatory conditions such as acute pancreatitis. This case report describes a rare extrapulmonary form of COVID-19, not yet described in the literature, and a possible correlation between viral inflammation and pancreatic involvement in an indigenous patient from Paranapua.

Contrast-enhanced intraoperative ultrasound (CE-IOUS) in patients with pancreatic cancer undergoing surgery: an initial experience

Purpose: The implementation of contrast-enhanced ultrasound represents an important innovation in hepato-pancreato-biliary imaging. Previous studies have validated contrast-enhanced intraoperative ultrasound (CE-IOUS) during liver surgery. Nonetheless, there is limited evidence regarding its use during pancreatic surgery. The purpose of the present study was to prospectively assess the potential role of CE-IOUS during pancreatic surgery for the evaluation of resectability/staging of the primary tumor, along with identification of potential liver metastases. Method: The protocol of the present study has been registered at clinicaltrials.gov (identifier: NCT04683497). Ten patients (60% males, mean age 61 years) underwent surgery for pancreatic cancer between November 2020 and January 2021. All patients underwent multidetector Computed Tomography (MDCT), Magnetic Resonance Imaging (MRI), IOUS and CE-IOUS using Sonovue©. Location of the primary tumor, relation to the main vessels, contrast medium uptake modalities, presence of liver metastases, and multifocal pancreatic involvement were evaluated. Results: Nine of the included patients presented pancreatic ductal adenocarcinoma and one patient presented acinar cell carcinoma (head:7, tail:3). Three new liver lesions (all metastases) were identified using CE-IOUS in two patients (20%) leading to a change of surgical plan (Whipple procedure with resection of segment IV in one patient and Whipple procedure with wedge resection in the second patient). All these new findings were diagnosed after contrast-enhancement; one injection was performed per lesion. Intraoperative findings regarding the location and characteristics of primary tumor did not differ from those obtained with preoperative imaging. Conclusions: According to our initial experience, CE-IOUS is a safe and efficient imaging modality with a direct impact on operation strategy.

Increased serum amylase and/or lipase in coronavirus disease 2019 (COVID-19) patients: Is it really pancreatic injury?

Coronavirus disease 2019 (COVID‐19) is a novel disorder caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Although it mainly affects the respiratory system, the pancreas could also become the virus' target. The issue regarding pancreatic involvement in COVID‐19 has been raised by several researchers. They found increased serum amylase and/or lipase in COVID‐19 patients, which suggested pancreatic injury. We aimed to critically review the evidence to provide insights and to answer the very question of the possibility of pancreatic injury. Current evidence shows that increased amylase and/or lipase is not necessarily a pancreatic injury in COVID‐19 patients. Those increased enzymes might also be found in other clinical conditions.

Postoperative Outcome of Surgery with Pancreatic Resection for Retroperitoneal Soft Tissue Sarcoma: Results of a Retrospective Bicentric Analysis on 50 Consecutive Patients

BackgroundsMultivisceral resection is the standard treatment for retroperitoneal sarcoma (RPS) during which pancreas resection may be necessary. MethodsAll consecutive patients operated for RPS with pancreatectomy in 2 expert centers between 1993 and 2018 were retrospectively analyzed. ResultsFifty patients (median age: 57 years, IQR: [46–65]) with a primary (n = 33) or recurrent (n = 17) RPS underwent surgery requiring pancreas resection (distal pancreatectomy (DP) (n = 43), pancreaticoduodenectomy (PD) (n = 5), central pancreatectomy (n = 1), and atypical resection (n = 1)). Severe postoperative morbidity (Clavien-Dindo III–IV) was observed in 14 patients (28%), and 7 of them (14%) required reoperation for anastomotic bowel leakage (n = 5), gastric volvulus (n = 1), or hemorrhage (n = 1). Pancreas-related complications occurred in 25 patients (50%): 10 postoperative pancreatic fistulas (POPF) (grade A (n = 12), grade B (n = 6), grade C (n = 1)), 13 delayed gastric emptying (grade A (n = 8), grade B (n = 4), grade C (n = 1)), 1 hemorrhage (grade C). Postoperative mortality was 4% (n = 2), all following PD, caused by a massive intraoperative air embolism and by a multiple organ failure after anastomotic leakage. Pathological analysis confirmed pancreatic involvement in 17 (34%) specimens. Microscopically complete resection (R0) was achieved in 22 (44%) patients. After a follow-up of 60 months, 36 patients (75%) were still alive, among whom 27 without recurrence (56%). ConclusionPancreatic resection during RPS surgery is associated with significant postoperative morbidity and mortality. PD should be avoided whenever possible while other procedures seemed achievable without excessive morbidity and with long-term survival.

Pancreatitis Associated with Viral Hepatitis: Systematic Review.

Background: We conducted a systematic review in order to summarize the available data on pancreatitis associated with viral hepatitis. Methods: A comprehensive literature search of Medline, Scopus and ISI Web of Science databases was conducted and papers eligible for the inclusion identified. Results: In total, 46 studies reporting data on 73 patients were included in the analysis. Most of the cases were diagnosed in Asia (57.53%), followed by North America (23.29%), and Europe (13.70%). Most of the patients were affected by hepatitis A virus (HAV) (42.47%), followed by hepatitis E virus (HEV) (28.77%), hepatitis B virus (HBV) (8.22%), and hepatitis C virus (HCV) (1.37%), while 17.81% at the time of diagnosis were classified as affected by “hepatitis virus”. Pancreatitis was severe in 32.88% of cases. The respiratory system was affected in 2.74% of patients, 6.85% experienced renal failure, while 5.48% experienced a multiorgan dysfunction syndrome (MODS). Four patients (5.48%) needed pancreatic surgery. Despite the treatment, 21.92% of patients died. We identified fulminant hepatitis (p < 0.0001), MODS (p < 0.0001) and severe pancreatitis (p < 0.0001) to be significantly more present in patients who died in comparison to cured ones. Conclusion: Increased awareness of pancreatic involvement in viral hepatitis is needed because it can have a substantial impact on therapeutic approaches and outcomes.

S1568 A Rare Cause of a Common Disease: Metastatic Lung Cancer Presenting as Acute Pancreatitis

INTRODUCTION: Lung cancer is the second most common cancer and is the leading cause of cancer-related death in the United States.1 Small Cell Lung Cancer (SCLC) makes up 15% of lung malignancies.2 It is usually diagnosed at a late stage with distant metastases mostly present at the time of diagnosis. CASE DESCRIPTION/METHODS: A sixty-three-year-old male with multiple medical comorbidities presented with symptoms of generalized malaise, weight loss, sharp upper abdominal pain and swelling. His labs were significant for leukocytosis, elevated transaminases, hyperbilirubinemia and lipase level of 401 U/L (Normal range 7-60 U/L).Subsequent imaging demonstrated a left hilar mass measuring 3.8 cm × 3.8 cm (Figure 1A) and pancreatic mass measuring 1.6 cm antero-posteriorly with upstream pancreatic duct dilation (Figure 1B).Endoscopic retrograde cholangiopancreatography (ERCP) was performed with successful placement of a biliary stent. In addition, an endoscopic ultrasound (EUS) was performed which demonstrated a mass in the body of the pancreas measuring 3.1 cm × 2.3 cm in maximal cross-sectional diameter with surrounding lymphadenopathy (Figure 1D). Sonographically, the liver appeared cirrhotic with several hypodense lesions concerning for metastatic deposits (Figure 1C). Fine needle aspiration (FNA) of the pancreatic mass as well as the hepatic lesions was performed (Figure 2A–D). Cytology was consistent with metastatic small cell neuroendocrine tumor. He was started on carboplatin and etoposide. He was unable to tolerate due to side effects and elected to pursue comfort care measures. DISCUSSION: Presenting symptoms of SCLC depend on disease location (i.e. progression in thoracic cavity versus distant metastatic disease) or a resultant paraneoplastic syndrome. Symptoms like cough and shortness of breath can occur in the setting of a hilar mass. Hepatic involvement which can occur in upwards of 50% of cases, can present as obstructive jaundice and carries a poor prognosis3. While metastasis to pancreas has been identified on autopsy, an index presentation of acute pancreatitis as a result of metastatic SCLC to the pancreas is relatively rare.4–8 EUS has emerged as the preferred modality to obtain a histological diagnosis in cases with pancreatic involvement in order to distinguish a primary pancreatic malignancy from metastatic SCLC.9Figure 1.: A. CT Chest with contrast showing a left hilar mass measuring 3.8 × 3.8 cm (red arrow). Calcified granuloma is also seen on right side (green arrow). B. CT Abdomen with contrast showing a pancreatic mass with distal pancreatic duct dilatation (red arrow). Heterogenous liver with no discrete intrahepatic masses (green arrow). C. EUS showing the left lobe of liver with multiple round hypoechoic lesions. D. EUS showing a hypoechoic, heterogenous and irregular pancreatic mass measuring 3.1 cm × 2.3 cm in maximal cross sectional diameter (red arrow).Figure 2.: A. Pancreas: (Hematoxylin &Eosin, ×100) small tumor cells with hyperchromatic molding nuclei and almost no cytoplasm (yellow arrow).Background of fibrin and red cells (red arrows). B. Liver (hematoxylin & eosin ×400) large eosinophilic cells (yellow arrow) showing normal hepatocytes mixed adjacent to cluster of small cells with hyperchromatic nuclei and essentially no cytoplasm (red arrow) showing small cell carcinoma tumor cells. C. Liver: (×400) cytokeratin AE1/AE3 immunoperoxidase stain decorating both large and benign hepatocytes and small neuroendocrine tumor cells. D. Liver: (×400) Chromogranin immunoperoxidase reactive in small neuroendocrine cells only (brown). The large background benign hepatocytes are non-reactive.Figure 3.: References.

Concurrent renal and pancreatic involvement as a presenting feature in acute lymphoblastic leukemia

Concurrent renal and pancreatic involvement as a presenting feature in acute lymphoblastic leukemia

S1387 A Case of Rapidly Progressive Disseminated Cytomegalovirus Causing Acute Pancreatitis in the Setting of Acquired Immune Deficiency Syndrome

INTRODUCTION: Widespread dissemination of opportunistic infections is increasingly recognized in AIDS, many times found on autopsy when causing gastrointestinal pathology. However, premortem acute pancreatitis caused by opportunistic infections is rarely diagnosed. CMW is a double stranded DNA with a reported prevalence of 60-100% (1). In an immunocompromised individual, disseminated CMV can cause a variety of pathology. We will discuss a middle aged female who was found to have acute pancreatitis in the setting of CMV viremia causing rapid deterioration. CASE DESCRIPTION/METHODS: 45 year old El Salvadorian female presented with abdominal pain, nausea, vomiting and diarrhea. Lipase on admission was 154 U/L. CT showed evidence of acute pancreatitis, gastritis and colitis. Denied alcohol use and triglyceride levels were normal. An MRCP did not show any obstruction of the bile duct. Patient became febrile and HIV test was positive with high viral load and CD4 count less than 20. Denies being sexually active but was raped while crossing the border two years prior. Course complicated by septic shock requiring intubation and vasopressors secondary to PCP pneumonia. Patient suffered from a GI bleed and EGD brushings showed candida throughout the upper GI tract. Biopsies of the gastric body, antrum and duodenum came back positive for CMV. CMV DNA was >20000 IU/ml and started on Ganciclovir. Repeat CT still showed evidence of acute pancreatitis. Patient went into renal failure requiring CVVH and ultimately the patient passed due to complications of septic shock. DISCUSSION: CMV in immunocompromised patients is common, but CMV pancreatitis is rare. A retrospective study analyzed autopsy CMV in AIDS patients and 81/164 had CMV infection, but organ failure was in 17 patients. Another study conducted autopsies on patients with CMV infections, and 10% were found to pancreatic involvement. The exact mechanism is still not well understood, but one proposed mechanism suggests endothelial cells release trypsin which results in pancreatic inflammation and autodigestion of cellular membranes. In this case, the patient met diagnostic criteria for pancreatitis by sharp epigastric abdominal pain with loss of appetite and CT findings of acute pancreatitis. Lipase levels are not correlated to the severity of disease, however in the three documented cases of CMV pancreatitis lipase was >1000 U/L. CMV should be on differential when a patient with AIDS presents with acute pancreatitis.

Prostate and pancreas involvement are linked in IgG4-related disease

ObjectiveProstate involvement by IgG4-related disease (IgG4-RD) is a rarely described organ manifestation and knowledge regarding its frequency and clinical features is limited. MethodsFrom a single-center cohort, 168 male patients were examined who satisfied the 2019 ACR/EULAR classification criteria or 2012 consensus histopathologic criteria for IgG4-RD. ResultsProstate involvement were identified in 25 (15%) of these cases. The majority of patients with IgG4-RD involving the prostate gland (80%) were symptomatic at presentation with incomplete voiding (64%), urinary frequency (52%), and urinary hesitancy (48%) being the most common complaints. The radiologic presentation of prostate disease is most often a focal abnormality suggesting inflammation rather than a mass lesion. While most patients with IgG4-related prostate disease (89%) experienced recurrence after or during glucocorticoid tapering, patients treated with B cell targeted therapy in this series experienced clinical improvement and were tapered off of glucocorticoids. Additionally, patients with IgG4-RD involving the pancreas (p = < 0.001) were more likely to have prostate involvement than were those with other types of organ involvement. ConclusionThis report provides the first comprehensive clinical description of IgG4-RD involving the prostate gland and links this manifestation with pancreatic involvement.

Study of association of pancreatitis with enteric fever of age group 1 to 15 years

Introduction: Enteric fever is endemic in India. 1% of children up to 17 years of age suffer from Enteric fever. Enteric fever is a systemic disease characterized by fever and abdominal pain caused by the dissemination of Salmonella typhi or S. paratyphi. The term enteric fever includes both typhoid fever and paratyphoid fever. Many case reports of severe acute pancreatitis during salmonellosis have been reported, suggesting that serious pancreatic disease may represent a complication of Salmonella infection. Aim and objective: To find out the frequency of acute pancreatitis considering clinical features, biochemical changes (serum amylase and lipase), and ultra-sonographic evidence of pancreatic involvement in the pediatric population by estimating serum amylase and lipase level in the pediatric population who were admitted with the diagnosis of Enteric fever. Material and Method: The present prospective study was conducted in the S V P PG Institute of pediatrics and SCB Medical College, Cuttack, Odisha, India which is a premier referral institute of eastern India. Result: Overall the proportion of patients with raised levels of serum amylase and lipase in the Enteric fever group was 44.68% (n=21). Comparing these values with the control group shows that the rise in serum amylase and serum lipase levels were statistically more significant (‘p’ value &lt;0.05). Conclusion: Hence, salmonella may be considered as a causative agent of subclinical pancreatitis with biochemical and radiological changes.