Pancreatic tuberculosis (TB) is a rare but important entity to consider when evaluating a pancreatic mass, especially in patients from endemic areas. Its clinical and radiologic features may mimic those of a pancreatic neoplasm, making it a difficult clinical diagnosis. We present a case of a 31-year-old Indian man who presented with fevers, night sweats, weight loss, and epigastric pain. Abdominal magnetic resonance imaging (MRI) showed a pancreatic head mass. Biopsy of the mass was consistent with pancreatic tuberculosis.

INTRODUCTION: The majority of “giant” hemangiomas remain asymptomatic with no cause for surgical intervention; however, this may not hold true for massive tumors. The following case will review the challenges facing both patients and physicians when managing these atypical tumors. CASE DESCRIPTION/METHODS: A 49-year-old male with no medical problems presented with complaints of post-prandial bloating, early satiety and mild epigastric discomfort. The bloating was intermittent for several years; however, symptoms have recently curtailed his eating habits. CBC, BMP and liver enzymes were unremarkable. An ultrasound highlighted a massively enlarged liver extending into the pelvis and displacing surrounding organs. The liver parenchyma appeared to be replaced with a homogenous, hyperechoic lesion. An MRI then illustrated a 29.5 × 20.1 × 19.4 cm, strongly hyperintense mass on T-2 weighted sequences consistent with the diagnosis of a hemangioma. He was referred to a hepatobiliary surgeon and an extended right hepatectomy was eventually performed. Histopathology results described vast endothelial lined channels supported by thin fibrous stroma without features of malignancy. The patient returned to clinic four weeks after surgery reporting complete resolution of his symptoms. DISCUSSION: Hemangiomas are the most common benign solid tumor of the liver with little to no risk of malignant transformation. Often discovered incidentally on imaging studies, the majority of these tumors remain indolent without the need for routine surveillance. Rarely these tumors become symptomatic, often correlating with tumor size. The definition of “giant” liver hemangioma remains controversial, with most authors assigning the label to tumors greater than 4cm or 5cm in size. It is for this reason that management of giant hemangiomas remains highly debated (i.e. observation versus resection). Recent studies have shown that tumors greater than 20cm in size pose a higher risk for GI symptoms related to mass effect on surrounding organs as well as causing a disturbance in the hematologic and coagulation systems. Surgical resection should be considered for symptomatic or complicated lesions, or when the diagnosis remains inconclusive. It is our belief that size classifications for giant hemangiomas requires further subgrouping to consider the danger of these massive tumors as well as the increased morbidity of surgery. Proper management of these tumors should be individualized to each patient and include a multidisciplinary team approach.

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INTRODUCTION: Cystoisosporiasis is an underrecognized gallbladder infection of immunocompetent hosts due in part to subtle histopathologic findings and low index of suspicion during examination of routine cholecystectomy specimens. This case will highlight the importance of detecting the organism in order to gain understanding of its life cycle and to raise awareness of the potential symptoms for those who become immunosuppressed. CASE DESCRIPTION/METHODS: A 65-year-old male with compensated cirrhosis presented with complaints of intermittent right upper quadrant pain for three months. He denied symptoms of diarrhea, jaundice, fever, chills, recent travel and sick contacts. CBC, BMP and liver enzymes were unremarkable. A right upper quadrant ultrasound illustrated multiple gallstones within the gallbladder along with wall thickening measuring up to 4.8 mm. The patient underwent a laparoscopic cholecystectomy with resolution of symptoms. Pathologic evaluation of the resected gallbladder described elongated “banana-shaped” zoites of C. belliwithin parasitopherous vacuoles in the gallbladder columnar mucosa. DISCUSSION: Cystoisospora belli (C. belli) is an intracellular protozoan of the intestinal epithelium often associated with gastrointestinal (GI) disease in immunocompromised patients or those who travel to endemic areas. The infection is acquired by fecal-oral route through ingestion of infective oocysts in contaminated water. Symptoms of C. belli include watery diarrhea, abdominal pain, nausea, vomiting and weight loss due to malabsorption, whereas most infected immunocompetent patients remain asymptomatic. C. belli is known to reside within parasitophorous vacuoles in epithelial cells of the small intestine; however, incidence of gallbladder infection is on the rise as there becomes an increased awareness and recognition on the part of the pathologist. Previously, lack of recognition has stemmed from multiple factors including a low index of suspicion in patients without clinical symptoms or those who remain immunocompetent, the underwhelming appearance of infected gallbladders with lack of significant tissue reaction, as well as the sparse distribution of the organisms themselves. The unexpectedly high prevalence in gallbladder specimens has given rise to the idea that the gallbladder may be an anatomic reservoir for this commensal organism in the immunocompetent host. For this reason, C. belli infection should be considered in patients exhibiting typical GI symptoms following immunosuppression.

A previously healthy, 20-year-old, heterosexual Japanese man was admitted to our hospital with a 3-day history of fever and pharyngalgia. On physical examination, his axillary temperature was 38 °C, and a furred soft palate and tonsils were seen. Endoscopy showed massive oropharyngeal shallow ulcers, and herpes simplex virus type 2 was demonstrated by immunohistochemical staining of biopsy specimens (a,b). After intravenous drip administration of acyclovir (5 mg/kg every 8 h) for 7 days, the patient improved markedly, as shown on follow-up endoscopy (c).