Isolated Pyogenic Pancreatic Abscess Mimicking

Vui Heng Chong
Gastroenterology Unit, Department of Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital.
Bandar Seri Begawan, Brunei Darussalam
ABSTRACT
Context Pancreatic abscesses are uncommon
and usually occur in the setting of
pancreatitis. Isolated pyogenic pancreatic
abscesses without any precipitating events are
extremely rare.
Case report A 72-year-old man with a two
month history of non-specific abdominal
discomfort, distension, anorexia and weight
loss was admitted for further evaluation. A
computer tomography scan showed a lesion
of the pancreatic head suspicious for a
malignancy. Unexpectedly,
Klebsialla
pneumoniae was isolated from the aspiration
biopsy without any evidence of malignancy.
A repeat CT scan four months later showed
resolution of the abscess after a six week
course of antibiotic.
Conclusion Our case highlights a rare case of
isolated pyogenic pancreatic abscess
secondary to Klebsialla pneumoniae mimicking
an underlying pancreatic malignancy.
Infective causes should be considered to
avoid any unnecessary major surgery.
INTRODUCTION
Pancreatic abscesses are uncommon and
usually occur in the setting of pancreatitis
especially if complicated by pseudocyts or
pancreatic necrosis. Infections outside of this
setting are extremely uncommon and have
been reported to occur with perforation of the
bowel into the pancreas [1, 2]. Imaging
findings can be non-specific and resemble
malignancies [2]. The case report presents a
72-year-old man who was diagnosed with
Klebsiella pneumoniae isolated pancreatic
head abscess mimicking a malignancy.
CASE REPORT
A 74-year-old man was admitted for
evaluation of a two-month history of
abdominal discomfort, distension, anorexia
and loss of weight. There was no history of
any fever. He had been having some difficulty
defecating, often passing only a small amount
of feces. Apart from the weight loss, there
were no warning symptoms. System reviews
were unremarkable. His past medical history
included long standing type II diabetes
mellitus, hyperlipidemia, previous fracture of
the neck of the femur and mild depressive
disorders. His medications included statins,
oral hypoglycemic agents and multivitamins.
On examination, he was afebrile, comfortable
and did not have features of significant weight
loss. The abdomen was generally distended
but not tender. There was no organomegaly.
The rest of the examination was
unremarkable.
Blood tests showed poorly controlled diabetes
with a random blood sugar level of 23.8
mmol/L (reference range: 3.5 to 6.0 mmol/L)
and an elevated erythrocyte sedimentation
rate of 93 mm/h (reference range: 0-10
mm/h). The liver function test was normal
apart from hypoalbumenia of 22 g/dL
(reference range: 35-40 g/dL). The results of
the routine blood tests, which included a full

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310
blood count and a thyroid function test,
together with serum calcium, amylase, urea,
and electrolytes, were all normal. Chest
radiography and ultrasound of the abdomen
were normal. In view of the history of
abdominal pain and constipation, he
underwent an endoscopy. Upper GI
endoscopy showed pangastritis with gastric
atrophy in the antrum and body. A biopsy for
Helicobacter pylori was negative. A
colonoscopy was normal. A computer
tomographic (CT) scan of the abdomen and
pelvis was requested and this showed a 3 cm
ill-defined lesion with low central attenuation
measuring approximately 2 cm located at the
head of the pancreas (Figure 1). The rest of
the pancreas appeared normal. The adjacent
intra-pancreatic common bile duct and the
pancreatic duct were normal. There was no
evidence of vessel or lymph node
involvement. The clinical suspicion was that
of pancreatic head neoplasm. Serum carbonic
anhydrase 19-9 (CA 19-9) was elevated (133
IU/mL; reference range: 0-34 IU/mL). Serum
carcinoembryogenic antigen (CEA) was
normal.
Based on the CT findings, the condition was
deemed resectable and the option of curative
surgical resection was discussed with the
patient and his relatives. However, in view of
his age, the family members were reluctant to
proceed with surgery without further
confirmation of the malignant status.
Therefore, a biopsy of the lesion was
organized. Using a 21 gauge spinal needle, a
CT scan-guided percutaneous aspiration
biopsy was performed. Surprisingly, only a
few milliliters of purulent fluid was aspirated
and this was sent for cytology and culture.
Cytology showed inflammatory cells without
evidence of malignancy. A culture yielded
Klebsiella pneumoniae which was sensitive to
most antibiotics tested. The patient was
started on intravenous imipenem (1 g tid) for
two weeks and continued with an additional
four weeks of penicillin. A repeat CT scan six
months post-discharge showed resolution of
the pancreatic head lesion. He is well after
two years of follow-up.
DISCUSSION
Pancreatic infections are commonly
associated with complications resulting from
pancreatitis. It is still associated with
significant mortality despite improvement in
medical care. It is possible that our patient
may have had low grade pancreatitis with the
resulting complication. However, apart from
the lesion in the pancreatic head, the rest of
the pancreas appeared completely normal on
CT scan. Isolated pancreatic abscesses are
less common and are often due to tuberculosis
[3, 4]. The clinical presentations and imaging
findings are non-specific and resemble
underlying malignancy. Diagnosis still
requires histopathological examinations [5].
However, such cases have been reported
mainly from endemic areas for tuberculosis.
Apart from complications resulting from
pancreatitis, pyogenic pancreatic abscesses
Figure 1. a. CT scan showing an ill defined poorly
enhancing lesion located at the head of pancreas lesion
suggestive of head of pancreas tumor. b. Hypodense
area measuring approximately 2 cm located at the
centre of the lesion with the rest of the pancreas
appearing normal.

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have been reported to occur in association
with foreign body perforations or seedlings
from the adjacent organs [1, 2, 6]. There are
very few reports of fish bone perforations of
the gastric wall into the pancreas leading to
abscess formation. All of these cases were
initially suspected to be pancreatic
malignancies. Pancreatic abscess secondary to
duodenal diverticulum perforation has also
been reported [7]. Our patient did not have
any diverticuli noted during the endoscopy.
However, it is possible that a small
diverticulum could have been missed since a a
side viewing duodenoscopy was not carried
out. Furthermore, the CT scan did not show
any evidence of perforation.
Isolated pyogenic pancreatic abscesses
without any underlying etiology are extremely
rare and have mainly been reported with
Salmonella infections [8, 9]. The only risk
factor for our patient was poorly controlled
diabetes mellitus. There was no evidence of
any biliary disease or either acute or chronic
pancreatitis from the history and
examinations. Our patient also did not give
any history to suggest foreign body ingestion.
Similar to other reports of pancreatic abscess
mimicking malignancy, our initial diagnosis
was tumor of the pancreatic head, especially
with the elevated CA 19-9. an isolated
pancreatic abscess was diagnosed when the
fluid aspirate yielded only Klebsiella
pneumoniae. Radiological imaging in our
patient did not show evidence of abscesses in
other locations and the colonoscopy did not
show any evidence of colonic pathology such
as diverticular disease. It is very likely that
the pancreatic involvement occurred by
means of hematogenous spread during a
transient episode of bacteriemia which had
been resolved before presentation. Poor
diabetes control is known to cause
compromised immunity resulting in increased
risk for infections [10]. Infections without
obvious sources are particularly common
among patients with diabetes mellitus. Our
own experience with liver abscesses shows
that diabetes mellitus is an important risk
factor for abscesses without other etiologies.
We did consider the possibility of an infection
co-existing with an underlying malignancy;
however, it was very unlikely that this was the
case in our patient. A repeat CT scan done
four months post discharge showed complete
resolution of the abscess and the patient has
remained in good health in the two years of
follow-up.
The use of endoscopic ultrasound (EUS) for
both diagnosis and treatment would be the
modality of choice for managing a case such
as ours. EUS has been shown to be very
sensitive and specific for the diagnosis of
pancreatic lesions especially with the use of
fine needle aspiration cytology. Furthermore,
it has therapeutic uses with a low risk for
complications. Therefore, all pancreatic head
lesions should be biopsied, particularly using
EUS. Even when EUS-guided fine needle
aspiration cytology is performed for a
pancreatic head lesion, the risk for tumor
seeding does not pose a problem as Whipple
surgery includes resection of the biopsy area.
In our case, we had used the CT-guided
percutaneous technique as we did not have the
possibility of performing EUS at that time.
With the introduction of contrast-enhanced
EUS, differentiation between malignant and
non-malignant disorders can now be made
with more precision. It may even obviate the
need for biopsy in the future and avoid
unnecessary interventions. However, in a
center such as ours where the expertise of
EUS is not available, surgery may need to be
considered in a pancreatic head lesion, even if
it later turns out to be infective in origin.
In conclusion, our case highlights a rare case
of isolated pyogenic pancreatic abscess
secondary to
Klebsiella pneumoniae
mimicking an underlying pancreatic
malignancy. Infective causes should be
considered to avoid any unnecessary major
surgery.
Received January 11
th
, 2008 - Accepted
February 5
th
, 2008
Keywords
Adenocarcinoma, Abscess,
Klebsiella pneumoniae
Conflict of interest The author has no
potential conflicts of interest

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JOP. J Pancreas (Online) 2008; 9(3):309-312.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 3 - May 2008. [ISSN 1590-8577]
312
Correspondence
Vui Heng Chong
Gastroenterology Unit
Department of Medicine
Raja Isteri Pengiran Anak Saleha (RIPAS)
Hospital
Bandar Seri Begawan
Brunei Darussalam
Phone: +673-877.8218
Fax: +673-224.2690
E-mail: chongvuih@yahoo.co.uk
Document URL: http://www.joplink.net/prev/200805/06.html
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