Granulomatous pancreatitis--granulomas in chronic pancreatitis

The cardiac autonomic nervous system: an introduction

In recent decades, numerous anatomical and physiological studies of the cardiac autonomic nervous system (ANS) have investigated the complex relationships between the brain and the heart. Autonomic activation not only alters heart rate, conduction, and hemodynamics, but also cellular and subcellular properties of individual myocytes. Moreover, the cardiac ANS plays an essential role in cardiac arrhythmogenesis. There is mounting evidence that neural modulation either by ablation or stimulation can effectively control a wide spectrum of cardiac arrhythmias. This article discusses anatomic aspects of the cardiac ANS, focusing on how autonomic activities influence cardiac electrophysiology. Specific autonomic triggers of various cardiac arrhythmias, in particular atrial fibrillation (AF) and ventricular arrhythmias, are also briefly discussed. Studies with heart-rate variability analysis indicate that, rather than being triggered by either vagal or sympathetic activity, the onset of AF can be associated with simultaneous discharge of both limbs, leading to an imbalance between these two arms of the cardiac ANS. At the same time, sudden cardiac death resulting from ventricular arrhythmias continues to be a significant health and societal burden. These nerve activities of the cardiac ANS can be targeted for the treatment for cardiac arrhythmias, in particular AF and ventricular tachyarrhythmias.

Isolated Pancreatic Tuberculosis Mimicking Pancreatic Cancer: A Diagnostic Challenge

Isolated pancreatic tuberculosis is an exceedingly rare condition, even in areas of the world where the disease is highly prevalent. Abdominal tuberculosis is a common form of extrapulmonary tuberculosis but involvement of the pancreas is very rare. We report a case of isolated pancreatic tuberculosis presenting as a pancreatic mass in a patient with persistent abdominal pain and jaundice. Clinically and radiologically, the mass mimicked a malignant pancreatic tumor with a vastly different prognostic implication and therapeutic approach. Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) can provide valuable diagnostic information in this scenario. After the tissue showed evidence of acid-fast bacilli and the cultures showed growth of Mycobacterium tuberculosis, antituberculosis therapy was initiated. Conservative management is usually successful in alleviating symptoms and leading to a cure. The excellent response to ATT makes it imperative that these patients are diagnosed early and managed appropriately to avoid unnecessary surgery and associated morbidity.

Pancreatic tuberculosis

Pancreatic tuberculosis is very rare, but recently, there has been a spurt in the number of reports on pancreatic involvement by tuberculosis. It closely mimics pancreatic cancer, and before the advent of better imaging modalities it was often detected as a histological surprise in patients resected for a presumed pancreatic malignancy. The usual presentation involves abdominal pain, loss of appetite and weight, jaundice which can be associated with cholestasis, fever and night sweats, palpable abdominal lump, and peripheral lymphadenopathy. Computed tomography (CT) of the abdomen is an important tool for evaluation of patients with pancreatic tuberculosis. This CT imaging yields valuable information about the size and nature of tubercular lesions along with the presence of ascites and lymphadenopathy. However, there are no distinctive features on CT that distinguish it from pancreatic carcinoma. Endoscopic ultrasound provides high resolution images of the pancreatic lesions as well as an opportunity to sample these lesions for cytological confirmation. The presence of granulomas is the most common finding on histological/cytological examination with the presence of acid fast bacilli being observed only in minority of patients. As there are no randomized or comparative studies on treatment of pancreatic tuberculosis it is usually treated like other forms of tuberculosis. Excellent cure rates are reported with standard anti tubercular therapy given for 6-12 months.

Granulomatous pancreatitis in a patient with acute manifested insulin-dependent diabetes mellitus

Isolated granulomatous noncaseating pancreatitis is a rare condition exceptionally described in human population. We demonstrate a case of the a 71-years-old female patient suffering from recent diabetes mellitus, generalized atherosclerosis and hypertension who died due to pulmonary embolism and terminal bronchopneumonia. Lipomatosis of pancreatic tissue was observed during the postmortem examination. Histological examination of pancreatic tissue discovered multiple small noncaseating epithelioid cell and giant cell granulomas, partly replacing the islets of Langerhans. To our knowledge, our case represents the first description of noninfectious granulomatous pancreatitis associated with acute manifested insulin-dependent diabetes mellitus.

Pancreatitis, Other Inflammatory Lesions, and Pancreatic Pseudotumors

The pancreas is versatile in the diversity of disorders that it can exhibit. In this article, characteristics of disorders such as chronic, autoimmune, eosinophilic, hereditary, and infectious pancreatitis are described. With regard to autoimmune pancreatitis, the role of clinical evaluation, histologic examination, and IgG4 immunohistochemistry is discussed. The role of pancreatitis in the pathogenesis of diabetes is also mentioned. Some implications of pancreatitis are highlighted, including the neoplastic predisposition caused by inflammatory lesions of the pancreas. The goal of this article is to convey an appreciation of these disorders because their recognition can benefit patients tremendously, as inflammatory lesions of the pancreas can be mass-forming, giving rise to pseudotumors, and leading to surgical resection that may otherwise be unnecessary.

Extrapulmonary sarcoidosis of liver and pancreas: A case report and review of literature

Sarcoidosis is a chronic multisystemic granulomatous disease of unknown origin, which can involve nearly all organs. In the case of an infrequent gastrointestinal tract involvement in systemic sarcoidosis, granulomas of the liver are most commonly described while isolated pancreatic sarcoid lesions are rarely seen. We report a case of systemic sarcoidosis with exclusive extrapulmonal involvement of the liver and the pancreas in a 71-year-old white man. The diagnosis of liver involvement was confirmed by biopsy. Pancreatic surgery was needed because preoperative evaluation could not exclude pancreatic cancer and for biliary decompression. An extensive literature review of systemic sarcoidosis, focusing on reported cases with unusual presentation of sarcoidosis in the liver and the pancreas, its diagnosis, treatment, and prognosis was made.

Pancreatic involvement in systemic sarcoidosis. A case report

We report a case of serum pancreatic hyperenzymemia as a primary manifestation of sarcoidosis; pancreatic involvement was confirmed by endoscopic ultrasonography which revealed a notable glandular fibrosis of the pancreas. It is important that patients with systemic sarcoidosis who have increased serum levels of amylase and lipase be checked in order to detect the presence of possible pancreatic involvement. Endoscopic ultrasonography represents the technique of choice used to confirm the clinical suspicion of pancreatic inflammation.

Expression of histocompatibility antigen HLA-DR on the epithelial cells of the pancreatic duct and thyroid follicle. An autopsy case

An autopsy case of chronic pancreatitis associated with unusual chronic thyroiditis in a 54-year-old woman is presented. Microscopically, the pancreas was densely infiltrated by lymphocytes and its exocrine parenchyma was completely replaced by sclerotic tissue. The thyroid gland was also infiltrated by lymphocytes, but no lymphoid follicles were observed. These morphological changes are rare findings with respect to the severity of inflammation and the association of the affected organs. Further findings suggested involvement of an autoimmune mechanism in the pathogenesis of these lesions. Using the avidin-biotin-conjugate technique and antibodies (Abs) against T lymphocyte and HLA-DR antigens (Ags), immunological aspects of the lesions were studied. Most of these infiltrating lymphocytes were revealed to be T lymphocytes, and HLA-DR Ags were observed on the epithelial cells of the pancreatic ducts and thyroid follicles. As a control, 45 surgical specimens of pancreas and thyroid gland were studied for detection of HLA-DR expression on the epithelial cells. One case of chronic pancreatitis was revealed to express HLA-DR Ag on the epithelium. The patient was a 44-year-old woman who had silently developed pancreatic cyst due to chronic inflammation. This finding also suggests a role of autoimmunity in the pathogenesis of chronic idiopathic pancreatitis.