A 65-year-old male was admitted to our hospital complaining of jaundice, pruritus, mild right upper abdominal pain and darkening urine. Past medical history revealed atrial fibrillation and the patient was on intermittent aspirin therapy. And the family history was negative. Physical examination revealed icteric sclera and skin, mild upper abdominal tenderness, arythmia, irregular heart sound and pulse deficit.
The laboratory test data at admission showed that the serum levels of alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyltransferase (gamma-GT), total bilirubin (TBil) and direct bilirubin (DBil) were elevated to 79 U/L (5-45 U/L), 51 U/L (5-35 U/L), 540 U/L (30-110 U/L), 197 U/L (7-50 U/L), 408 mumol/L(0-20.5 mumol/L) and 283.7 mumol/L (0-6.8 mumol/L), respectively. Serum IgG and IgM were 3,180 mg/dL (694-1620 mg/dL) and 344 mg/dL (60-263 mg/dL), respectively. The titer of antinuclear antibody (ANA) was 1:320. Screening for antoimmune diseases revealed that the patient was positive for antimitochondrial antibody (AMA), anti-AMA-M2 and anti-Ro antibody. Common tumor markers and viral markers were all negative.
Both computed tomography (CT) and magnetic resonance image (MRI) revealed diffusive enlargement of the pancreas, capsuled by an armorlike low-density rim and enhanced homogenously (Figure 1). Other abnormalities included significant dilation of intra- and extra-hepatic bile duct, diffusive thickening of the gallbladder wall and atrophy of the right kidney. Endoscopic retrograde cholangio-pancreatography (ERCP) was conducted, revealing similar findings with CT and MRI. No sign of malignancy was observed. Test of tumor markers from the bile showed CEA of 66.89 ng/mL (0-5 ng/mL) and CA199 larger than 4000 U/mL (<37.0 U/mL), but examinations of exfoliated cells proved negative for three consecutive times. The biliary culture was positive for ESBL-producing Klebsiella pneumoniae. Infection was suspected and meropenem (0.5 g per 8 hours) was administered.
Based on the biochemical evidence of cholestasis from the elevation of ALP, gamma-GT and TBil, and the presence of AMA, the patient was clinically diagnosed with PBC and UDCA (250 mg, three times per day) was initiated immediately after nasobiliary drainage, which partially improved the patient's liver function (Figure 2). Since the patient was also suspected of suffering from AIP, the following examinations were conducted. IgG4 was measured and turned out to be 44.36 g/L (0.03-2 g/L). CT-guided pancreatic biopsy was performed, and histopathological evaluation showed dense lymphoplasmacytic infiltration and fibrosis. IgG4+ plasma cell was stained and counted to be as high as 95 per high-power field (HPF) (Figure 3). ECT of salivary gland was normal. So the diagnosis of type I AIP was confirmed in accordance with the diagnostic criteria.
Steroid therapy with intravenous methylprednisolone (MEP) (40 mg per day) was administered promptly. Serum ALP, gamma-GP, TBil and DBil just before steroid therapy were 376 U/L, 38 U/L, 404.9 mumol/L and 289.2 mumol/L, respectively, and one week later were 243 U/L, 47 U/L, 47 U/L, 206.1 mumol/L and 167.1 mumol/L, respectively. Then we stepped down the steroid therapy with oral MEP 32 mg daily, yet the serum liver enzymes and bilirubin bounced up. So we increased the dose to 32 mg in the morning and 16 mg in the afternoon. And then the laboratory values improved. A repeat MRI showed remarkable reduction of the pancreas. 40 days after treatment, the IgG and IgM returned back into the normal range. The serum levels of ALP, gamma-GP, TBil and DBil were 135 U/L, 134 U/L, 82.8 mumol/L and 54.9 mumol/L, respectively. The patient was discharged and followed up at the clinic with MEP tapered off weekly by 5 mg. The clinical course is depicted in Figure 2.
About 40 days after discharge, the patient developed red maculopapules on his right chest with prickling-like pain, worsened with erosion and blisters. The patient was diagnosed with herpes zoster and treated with acyclovir (500 mg twice a day) for 9 days. Unfortunately for the patient, a chest X-ray later showed multiple nodules in the right lung. Chest CT displayed multiple patchy shadows with cavity. CT-guided lung biopsy showed neutrophil aggregation and fibrous effusion within the alveoli. The patient was diagnosed with pulmonary abscess and was treated effectively with moxifloxacin (Figure 1). Given the immunosuppressed status of the patient, thymosin was injected twice a week to restore the immune function. The liver function and immunological indices of the patient were normal during the subsequent one-year follow-up period.
CT and MRI scan of the patient. Chest CT (H) showed a large patchy shadow in the right lower lobe.