Case 3-2006

Abstract

398 From the Gastrointestinal Unit (R.H.S.) and the Departments of Radiology (M.M.M.) and Pathology (J.M.), Massachusetts General Hospital; and the Departments of Medicine (R.H.S.), Radiology (M.M.M.) and Pathology (J.M.), Harvard Medical School. N Engl J Med 2006;354:398-406. Pr e sen tat ion of C a seA 63-year-old woman was admitted to the hospital for evaluation of a pancreatic mass.Four months before admission, the patient noticed dysuria and dark urine. The results of urinalysis showed 3+ bilirubin and 2+ occult blood and were otherwise normal. A urinary tract infection was diagnosed, and levofloxacin was prescribed. A urine culture subsequently showed no growth of bacteria. Five days after the urinalysis, she went to a local hospital emergency department, where she said that she had had dark urine, pruritus, and intermittent epigastric pain for the preceding 10 days; a weight loss of 5 kg during the past 3 months; and lightening of the color of her stool and a small purple area on her right arm for the past several days. The patient had not had fever, chills, nausea, vomiting, or diarrhea. Abdominal computed tomography (CT) revealed dilatation of the intrahepatic and extrahepatic ducts and enlargement of the pancreatic head. She was transferred to this hospital and admitted.The vital signs were normal. On examination, the patient appeared well and was alert and oriented but jaundiced. The sclerae were icteric, and there was an ecchymosis (2 cm in diameter) on her right thigh; the remainder of the physical examination was normal. The levels of electrolytes, calcium, phosphorus, magnesium, and serum lipids; the results of renal-function studies; and the white-cell, differential, and platelet counts were normal. The results of other laboratory tests are shown in Table 1. A chest radiograph showed two small ill-defined opacities at both lung apexes. Abdominal and pelvic CT scanning on the second hospital day, performed after the administration of oral and intravenous contrast material, revealed dilated intrahepatic and extrahepatic bile ducts; a periportal lymph node that was 7 mm in diameter; a periportal mass, 3.1 cm by 3.6 cm; a complex cystic mass, 2.9 cm by 2.4 cm, in the pancreatic head; another complex cystic mass, 2.7 cm by 1.4 cm, adjacent to the pancreatic tail; and a low-density splenic lesion.Abdominal ultrasonography on the next day confirmed the presence of dilated intrahepatic and extrahepatic bile ducts and a complex cystic mass in the pancreatic head. She had a normal gallbladder. Endoscopic upper-abdominal ultrasonography revealed no abnormalities in the esophagus, stomach, or duodenum. There was a round, thick-walled cystic mass in the pancreatic head, 2.9 cm by 2.4 cm, that abutted

Clinical and ultrasonographic features of abdominal tuberculosis in HIV positive adults in Zambia

“…In contrast to a previous study [8], ascites was the most common manifestation in these HIV positive patients. Although it has been described [18], we did not find any ultrasound evidence of pancreatic involvement, but we did not measure serum amylase or lipase.…”

“…Over a period of 27 weeks, from September 2005 until May 2006, all patients admitted to the medical wards of UTH were reviewed by conducting twice weekly ward rounds specifically for this purpose. The inclusion criteria were fever and weight loss, with one or more of the following: diarrhoea persisting for >1 month, ascites, abdominal lymphadenopathy based on ultrasound, mesenteric masses based on ultrasound, hepatomegaly or splenomegaly, pancreatic enlargement based on ultrasound [18] or severe, unexplained focal or generalized abdominal tenderness persisting for 7 days or more. Assessment of weight loss was subjective only, based upon the patient's recollection.…”