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It is only for medical professionals to read and reference.
Clinically, when we see the sausage-like pancreas, we naturally associate it with autoimmune pancreatitis, but the sausage-like pancreas is not unique to autoimmune pancreatitis.
Today, I will share with you a different sausage-like pancreas.
▌ A 42-year-old male patient with medical history came to the hospital for treatment with epigastric pain, nausea and fever.
He has a history of advanced AIDS (AIDS) and no history of drinking.
▌ On physical examination, there is mild tenderness in the upper abdomen.
▌ Laboratory examination of white blood cells (5.
7×109/L), platelets (156×109/L) are normal, amylase (163U/L, reference range 26～102U/L) and lipase (84U/L, reference range 12~ 61 U/L), HIV-1 RNA was 16200 copies/mL, and CD4 T lymphocyte count was 6/microl.
Triglyceride levels are normal.
▌ Auxiliary CT examination showed that the pancreas had a sausage-like appearance with mesenteric edema (Figure 1A).
Endoscopic ultrasonography (EUS) showed diffuse hypoechoic enlargement of the pancreas (Figure 1B).
Further examination of the fine-needle aspiration biopsy tissue is shown in Figure 1C-E.
Figure 1.
Auxiliary examinations for the patient From the results of these auxiliary examinations, what is the possible diagnosis for this patient? ▌ Histopathological examination of the diagnosed patient showed diffuse infiltration of tissue cells (Figure 1C).
Immunohistochemical staining was positive for CD68 (Figure 1D), and negative for S100, HMB45, and keratin AE1/AE3.
The special staining of acid-fast bacilli showed that there are coryneform bacteria in the macrophages (Figure 1E), which is consistent with the infection of Mycobacterium avium (MAC).
Subsequent blood cultures were also positive for MAC, so the cause of the patient's acute pancreatitis should be: disseminated MAC infection.
▌ Treatment and follow-up After the diagnosis was confirmed, rifabutin, moxifloxacin, ethambutol and amikacin were added to the treatment, and antiretroviral therapy (ART) was also initiated again, but the patient subsequently lost Visited, so the follow-up treatment effect is unknown.
Q1Which other diseases can sausage-like pancreas be found in? Diffuse enlargement of the pancreas with a sausage-like appearance is a characteristic CT manifestation of autoimmune pancreatitis (AIP) (Figure 2).
However, this performance is not unique to AIP.
Diffuse pancreatic involvement can occur in various inflammatory, infectious, invasive, and neoplastic diseases.
Therefore, when observing the pancreas with this characteristic, the differential diagnosis should be made with caution.
Important ways for further differential diagnosis include serological testing (IgG4 levels, blood culture, tumor markers) and pancreatic histological biopsy (fine needle aspiration via endoscopic ultrasonography).
Figure 2.
"Sausage-like" pancreas of AIP patients Q2AIDS patients are more likely to have MAC infection? With the gradual application of ART to the treatment of AIDS patients, the risk of MAC infection in AIDS patients has shown a downward trend.
In the literature published 20 years ago, the incidence of MAC infection in AIDS patients was 20%-40%, but recently published The results of the study show that the incidence of this infection has been reduced to ≤2/1000 person-years.
Q3What are the risk factors for MAC infection in AIDS patients? Although under the current medical level, the probability of concurrent MAC infection in AIDS patients has been significantly reduced, the risk of infection in patients can increase with the appearance of the following factors: CD4 count <50/microl, HIV RNA>1000 copies/ During the treatment of ml, ART, the virus is still highly replicated, and the past or current is combined with opportunistic infections.
In addition, different regions, genetic susceptibility, history of bronchoscopy, eating unprocessed mature fish and seafood, and the use of granulocyte stimulating factors may be related to MAC infection in AIDS patients.
Q4What are the clinical manifestations of AIDS patients after MAC infection? There are two forms of MAC infection in AIDS patients: disseminated and localized MAC infection.
Disseminated MAC infection mostly appeared before ART was widely used.
The clinical manifestations of patients mainly include fever, night sweats, abdominal pain, diarrhea, and weight loss.
Localized MAC infection often occurs when ART treatment is initiated and the patient develops immune reconstitution syndrome.
The main clinical manifestations are fever and local lymphadenitis (such as neck, abdomen, mediastinum).
Uncommon clinical manifestations include spinal MAC infection, mastitis, necrotizing subcutaneous nodules, osteomyelitis, bursitis, granulomatous hepatitis, paravertebral abscess, brain abscess, etc.
Q5How to diagnose? CT is an important initial examination method for the diagnosis of MAC infection.
Through CT, lymph node lesions, hepatosplenomegaly, and small intestinal wall thickening of patients with disseminated MAC infection can be observed; the mesentery of patients with localized MAC infection can also be observed.
/ Enlargement of the lymph nodes in the abdomen.
After the CT examination is completed, the disease can be further diagnosed through histological biopsy and blood culture of the diseased organ according to the location of the disease.
Among them, disseminated MAC infection is usually diagnosed by blood culture and histological biopsy, but blood culture for localized MAC infection is usually negative, and it is usually diagnosed by biopsy of diseased lymph nodes.
Q6 How to treat? For AIDS patients diagnosed with MAC infection, a combination therapy strategy should be adopted.
The main purpose of this is to reduce drug resistance.
Specific drugs include: a macrolide (clarithromycin, 500mg, bid, po; azithromycin, 500-600mg, qd, po), ethambutol (15mg/kg, qd, po), rifol Pudding (300mg, qd, po), quinolones (levofloxacin, 500mg, qd, po; moxifloxacin, 400mg, qd, po) and aminoglycoside antibiotics (amikacin, 10-15mg/kg, iv, maintenance 2~3 months).
The initial treatment for most patients is macrolides + ethambutol.
For patients who have failed ART treatment, rifabutin should be added to the initial treatment.
It should be noted that after the diagnosis of AIDS patients with MAC, the patients who stopped ART treatment should restart ART.
In addition, the duration of treatment for this disease should be at least 12 months, and the CD4 count should be stable at 100/microl or more for 6 months Can consider stopping the drug.
Q7 How to prevent? For patients who have started ART therapy and have a CD4 count of <50 pcs/microL, there is no need for routine MAC prevention.
For other patients, prevention can be done by taking any of the following drugs: azithromycin (1200mg, qw, po), clarithromycin (500mg, bid, po) or rifabutin (300mg, qd, po).
References: [1] Castillo Almeida NE, Muppa P, Saleh OA, Deciphering the "Sausage" Pancreas, Gastroenterology (2021), doi: https://doi.
org/10.
1053/j.
gastro.
2021.
04.
052.
[2 ]Nightingale SD,Byrd LT,Southern PM,et al.
Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients.
J Infect Dis 1992;165:1082.
[3]Chaisson RE,Moore RD,Richman DD, et al.
Incidence and natural history of Mycobacterium avium-complex infections in patients with advanced human immunodeficiency virus disease treated with zidovudine.
The Zidovudine Epidemiology Study Group.
Am Rev Respir Dis 1992;146:285.
[4]Buchacz K,Lau B, Jing Y,et al.
Incidence of AIDS-Defining Opportunistic Infections in a Multicohort Analysis of HIV-infected Persons in the United States and Canada,2000-2010.
J Infect Dis 2016;214:862.
[5]Collins LF,Clement ME ,Stout JE.
Incidence,Long-Term Outcomes,and Healthcare Utilization of Patients With Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome and Disseminated Mycobacterium avium Complex From 1992-2015.
Open Forum Infect Dis 2017;4:ofx120.
[6]Buchacz K,Baker RK,Palella FJ Jr,et al.
AIDS-defining opportunistic illnesses in US patients,1994-2007:a cohort study.
AIDS 2010;24:1549.
[7]Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.
Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-infected Adults and Adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.
https:// clinicalinfo.
hiv.
gov/sites/default/files/inline-files/adult_oi.
pdf(Accessed on December 27, 2020).
Clinically, when we see the sausage-like pancreas, we naturally associate it with autoimmune pancreatitis, but the sausage-like pancreas is not unique to autoimmune pancreatitis.
Today, I will share with you a different sausage-like pancreas.
▌ A 42-year-old male patient with medical history came to the hospital for treatment with epigastric pain, nausea and fever.
He has a history of advanced AIDS (AIDS) and no history of drinking.
▌ On physical examination, there is mild tenderness in the upper abdomen.
▌ Laboratory examination of white blood cells (5.
7×109/L), platelets (156×109/L) are normal, amylase (163U/L, reference range 26～102U/L) and lipase (84U/L, reference range 12~ 61 U/L), HIV-1 RNA was 16200 copies/mL, and CD4 T lymphocyte count was 6/microl.
Triglyceride levels are normal.
▌ Auxiliary CT examination showed that the pancreas had a sausage-like appearance with mesenteric edema (Figure 1A).
Endoscopic ultrasonography (EUS) showed diffuse hypoechoic enlargement of the pancreas (Figure 1B).
Further examination of the fine-needle aspiration biopsy tissue is shown in Figure 1C-E.
Figure 1.
Auxiliary examinations for the patient From the results of these auxiliary examinations, what is the possible diagnosis for this patient? ▌ Histopathological examination of the diagnosed patient showed diffuse infiltration of tissue cells (Figure 1C).
Immunohistochemical staining was positive for CD68 (Figure 1D), and negative for S100, HMB45, and keratin AE1/AE3.
The special staining of acid-fast bacilli showed that there are coryneform bacteria in the macrophages (Figure 1E), which is consistent with the infection of Mycobacterium avium (MAC).
Subsequent blood cultures were also positive for MAC, so the cause of the patient's acute pancreatitis should be: disseminated MAC infection.
▌ Treatment and follow-up After the diagnosis was confirmed, rifabutin, moxifloxacin, ethambutol and amikacin were added to the treatment, and antiretroviral therapy (ART) was also initiated again, but the patient subsequently lost Visited, so the follow-up treatment effect is unknown.
Q1Which other diseases can sausage-like pancreas be found in? Diffuse enlargement of the pancreas with a sausage-like appearance is a characteristic CT manifestation of autoimmune pancreatitis (AIP) (Figure 2).
However, this performance is not unique to AIP.
Diffuse pancreatic involvement can occur in various inflammatory, infectious, invasive, and neoplastic diseases.
Therefore, when observing the pancreas with this characteristic, the differential diagnosis should be made with caution.
Important ways for further differential diagnosis include serological testing (IgG4 levels, blood culture, tumor markers) and pancreatic histological biopsy (fine needle aspiration via endoscopic ultrasonography).
Figure 2.
"Sausage-like" pancreas of AIP patients Q2AIDS patients are more likely to have MAC infection? With the gradual application of ART to the treatment of AIDS patients, the risk of MAC infection in AIDS patients has shown a downward trend.
In the literature published 20 years ago, the incidence of MAC infection in AIDS patients was 20%-40%, but recently published The results of the study show that the incidence of this infection has been reduced to ≤2/1000 person-years.
Q3What are the risk factors for MAC infection in AIDS patients? Although under the current medical level, the probability of concurrent MAC infection in AIDS patients has been significantly reduced, the risk of infection in patients can increase with the appearance of the following factors: CD4 count <50/microl, HIV RNA>1000 copies/ During the treatment of ml, ART, the virus is still highly replicated, and the past or current is combined with opportunistic infections.
In addition, different regions, genetic susceptibility, history of bronchoscopy, eating unprocessed mature fish and seafood, and the use of granulocyte stimulating factors may be related to MAC infection in AIDS patients.
Q4What are the clinical manifestations of AIDS patients after MAC infection? There are two forms of MAC infection in AIDS patients: disseminated and localized MAC infection.
Disseminated MAC infection mostly appeared before ART was widely used.
The clinical manifestations of patients mainly include fever, night sweats, abdominal pain, diarrhea, and weight loss.
Localized MAC infection often occurs when ART treatment is initiated and the patient develops immune reconstitution syndrome.
The main clinical manifestations are fever and local lymphadenitis (such as neck, abdomen, mediastinum).
Uncommon clinical manifestations include spinal MAC infection, mastitis, necrotizing subcutaneous nodules, osteomyelitis, bursitis, granulomatous hepatitis, paravertebral abscess, brain abscess, etc.
Q5How to diagnose? CT is an important initial examination method for the diagnosis of MAC infection.
Through CT, lymph node lesions, hepatosplenomegaly, and small intestinal wall thickening of patients with disseminated MAC infection can be observed; the mesentery of patients with localized MAC infection can also be observed.
/ Enlargement of the lymph nodes in the abdomen.
After the CT examination is completed, the disease can be further diagnosed through histological biopsy and blood culture of the diseased organ according to the location of the disease.
Among them, disseminated MAC infection is usually diagnosed by blood culture and histological biopsy, but blood culture for localized MAC infection is usually negative, and it is usually diagnosed by biopsy of diseased lymph nodes.
Q6 How to treat? For AIDS patients diagnosed with MAC infection, a combination therapy strategy should be adopted.
The main purpose of this is to reduce drug resistance.
Specific drugs include: a macrolide (clarithromycin, 500mg, bid, po; azithromycin, 500-600mg, qd, po), ethambutol (15mg/kg, qd, po), rifol Pudding (300mg, qd, po), quinolones (levofloxacin, 500mg, qd, po; moxifloxacin, 400mg, qd, po) and aminoglycoside antibiotics (amikacin, 10-15mg/kg, iv, maintenance 2~3 months).
The initial treatment for most patients is macrolides + ethambutol.
For patients who have failed ART treatment, rifabutin should be added to the initial treatment.
It should be noted that after the diagnosis of AIDS patients with MAC, the patients who stopped ART treatment should restart ART.
In addition, the duration of treatment for this disease should be at least 12 months, and the CD4 count should be stable at 100/microl or more for 6 months Can consider stopping the drug.
Q7 How to prevent? For patients who have started ART therapy and have a CD4 count of <50 pcs/microL, there is no need for routine MAC prevention.
For other patients, prevention can be done by taking any of the following drugs: azithromycin (1200mg, qw, po), clarithromycin (500mg, bid, po) or rifabutin (300mg, qd, po).
References: [1] Castillo Almeida NE, Muppa P, Saleh OA, Deciphering the "Sausage" Pancreas, Gastroenterology (2021), doi: https://doi.
org/10.
1053/j.
gastro.
2021.
04.
052.
[2 ]Nightingale SD,Byrd LT,Southern PM,et al.
Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients.
J Infect Dis 1992;165:1082.
[3]Chaisson RE,Moore RD,Richman DD, et al.
Incidence and natural history of Mycobacterium avium-complex infections in patients with advanced human immunodeficiency virus disease treated with zidovudine.
The Zidovudine Epidemiology Study Group.
Am Rev Respir Dis 1992;146:285.
[4]Buchacz K,Lau B, Jing Y,et al.
Incidence of AIDS-Defining Opportunistic Infections in a Multicohort Analysis of HIV-infected Persons in the United States and Canada,2000-2010.
J Infect Dis 2016;214:862.
[5]Collins LF,Clement ME ,Stout JE.
Incidence,Long-Term Outcomes,and Healthcare Utilization of Patients With Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome and Disseminated Mycobacterium avium Complex From 1992-2015.
Open Forum Infect Dis 2017;4:ofx120.
[6]Buchacz K,Baker RK,Palella FJ Jr,et al.
AIDS-defining opportunistic illnesses in US patients,1994-2007:a cohort study.
AIDS 2010;24:1549.
[7]Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.
Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-infected Adults and Adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.
https:// clinicalinfo.
hiv.
gov/sites/default/files/inline-files/adult_oi.
pdf(Accessed on December 27, 2020).
