A previously healthy 38-year-old gentleman began to experience episodes of intermittent abdominal pain five days prior to presentation. The abdominal pain was predominantly in the epigastrium, nonradiating, and occasionally associated with nausea. He did not have any episodes of vomiting or diarrhea. Over the course of next five days, he noticed yellowing of his eyes and urine which prompted him to visit the emergency room. Patient denied any history of fever, night sweats, weight loss, or decreased appetite. Family history was unremarkable. He migrated to the United States at the age of 33 from the Philippines. He had received BCG vaccination during childhood but had no previous history of treatment for tuberculosis. He denied any sick contacts or travel within the last few years. He worked as a pharmacist. He denied smoking and alcohol or intravenous drug use.
The patient appeared well nourished with icteric sclera. Physical examination revealed a temperature of 38 C, blood pressure 110/55 mmHg, heart rate 85 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 95% on room air. Cardiopulmonary examination was normal. Abdominal examination revealed tenderness in the epigastric region with no guarding or rigidity. However, no palpable mass could be appreciated.
Routine laboratory investigations showed normochromic normocytic anemia with Hb 12.3 gm/dl. Total bilirubin was 2.9 mg/dl while aspartate aminotransferase 167 U/L, alanine aminotransferase 443 U/L, and alkaline phosphatase were 424 U/L, respectively. Serum lipase and amylase were not elevated.
The chest radiograph at the time of admission was normal. Subsequently, he underwent an abdominal computed tomography (CT) scan which revealed a 3.8 x 2.7 cm solid mass posterolateral to the pancreatic head, suggestive of peripancreatic lymphadenopathy. Magnetic resonance imaging (MRCP) showed a 4.1 x 2.6 cm mass in the pancreatic head encasing the portal vein with multiple central areas of nonenhancement (Figure 1). There was a 1.5 cm segment of narrowing in the mid common bile duct with mild dilation of the intrahepatic ducts. The pancreatic duct was not dilated.
The differential diagnosis included malignant pancreatic tumor, autoimmune pancreatitis, neuroendocrine tumor, and gastrointestinal stromal tumor. Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) was performed which showed a heterogeneous hyperechoic pancreatic lesion which on histopathology revealed areas of coagulation necrosis, lymphocytes, and epithelioid histiocytes suggestive of granulomatous inflammation (Figure 2).