Spontaneous cure, followed by fatal complication in a patient with recurrent pancreatic pseudocyst

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Case 2: A 38 year– old HCV infected African American man on dialysis for ESRD due to focal segmental glomerulosclerosis. A liver biopsy showed chronic portal inflammation. Interferon alfa–2b therapy (3 million units TIW) was initiated. At week 4 of therapy he presented with a low– grade fever, pain, and erythema over his left arm. He was found to have an infection of a Gortex vascular access graft that had been placed 2 months prior to the initiation of interferon. The access graft was removed and eventually replaced. Interferon alfa–2b was restarted 2 weeks later. Two months passed and he presented with severe prostatitis requiring hospitalization and the treatment with IV antibiotics. The interferon therapy was discontinued. In summary, two patients with ESRD on interferon therapy had severe bacterial infections necessitating the discontinuation of therapy. Our review of the literature shows that these are the first reported cases of severe bacterial infections occurring in ESRD patients treated with interferon therapy. We suggest that in the setting of ESRD and interferon therapy, patients be monitored carefully for signs of infection. 496 PSEUDOPAPILLARY TUMOR OF THE PANCREAS PRESENTING WITH ACUTE PANCREATITIS Rajeev Jayadevan, M.D., Nejat Kiyici, M.D., Mario Ricci, M.D., Hilary Hertan, M.D.* and Capecomorin Pitchumoni, M.D. Gastroenterology, Our Lady of Mercy Medical Center, Bronx, NY. Purpose: Pancreatic pseudopapillary tumors, also known as papillary epithelial neoplasms, are rare tumors that occur mostly in young women. Often slow– growing and incidentally diagnosed, they account for only 1–2% of pancreatic exocrine tumors. We report a case of pseudopapillary tumor that presented with acute pancreatitis. A 21 year old Hispanic man was admitted with severe abdominal pain, nausea and vomiting since two days. Previously in good health, he denied alcohol use and was on no medication. He was in moderate pain, but had normal vital signs. Epigastric tenderness and fullness was noted; bowel sounds were present. Chest was clear to auscultation. Significant lab abnormalities included WBC–16.4 X 103/␮l, serum amylase–205 U/L, lipase 156 U/L, LDH–1023 U/L, AST 122 U/L, Glucose 164 mg/dl. Endocrine profile was normal. CXR was normal. CT scan of the abdomen showed a round, homogenous 8 cm mass in the region of the head of the pancreas, with normal appearance of the body and tail. EUS showed the mass to be hypodense, well circumscribed and arising from the pancreas, with no evidence of portal vein involvement. Pancreatitis resolved on conservative treatment. After CT– guided needle aspiration revealed a cellular epithelial neoplasm, he underwent Whipples procedure and recovered uneventfully. Biopsy of the mass revealed a solid– cystic papillary epithelial neoplasm, focally invading the duodenal submucosa but with free surgical margins. A few lymph nodes were removed and found to be free of tumor. Discussion: Pancreatitis is an extremely rare presentation of pseudopapillary tumors, most of which are benign and asymptomatic. They are low grade when malignant, and rarely metastasize. Prognosis is good after removal. 497 SYSTEMIC VASCULITIS PRESENTING WITH ABDOMINAL PAIN AND METABOLIC ACIDOSIS Umesh Sharma, M.D., Hamid Mojab, M.D., Sriram Yennurajalingam, M.D., Sita Chokhavatia, M.D.* and Adriana Opran, M.D. Internal Medicine, Mt. Sinai Services at Queens Hospital Center, Jamaica, NY. Purpose: Vasculitis is characterized by inflammation of blood vessels resulting in vascular necrosis. Systemic vasculitis can be primary or secondary A 37 year old Hispanic female presented with 3 days of non– colicky abdominal pain; 2 episodes of vomiting; non– bloody, watery diarrhea and productive cough. She was lethargic, heart rate – 127/min, blood pressure–

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192/124mmHg, afebrile with periumbilical tenderness. Laboratory data: hemoglobin 12 gm/dL (12.1–15.1), hematocrit 37.2% (36.1– 44.3) WBC count 13.1K cells/mm3 (3.8 –9.8), bands 11% (0 – 4), lymphocytes 9% (16 – 45), anisocytosis, polychromasia; sodium 130.7meq/dL (135–145), bicarbonate 20.8 meq/dL (20 –24), creatinine 1.3mg/dL (0.5–1.7), glucose 122mg/dL (75–115); urine analysis: specific gravity– 1.025, proteins 3⫹, trace ketones, large blood, small bilirubin, moderate bacteria few epithelial cells; erythrocyte sedimentation rate 112 mm/hr (0 –30); EKG – sinus tachycardia; chest xray– right middle lobe infiltrate. Empiric ceftriaxone and clarithromycin were given for presumed pneumonia and urosepsis. Over the next 2 days she developed livido reticularis; worsening diarrhea, vomiting, metabolic acidosis (bicarbonate 14.7); left foot drop; ventricular tachycardia; acute myocardial infarction was ruled out and esmolol, lidocaine and bicarbonate were begun. Echocardiogram revealed 4 chamber dilation and severely reduced left ventricular contractility. Abdominal CT scan: hepatomegaly, thick gall bladder wall, enlarged edematous pancreas, thickened bowel wall and mucosal edema suggestive of bowel ischemia. Additional laboratory data: PT 19.4 sec (11–13.3), INR 2.74, PTT 30.8 sec (21–32), FDP ⬎40mg/ml (⬍8), fibrinogen 200.4 mg/dL (150 –360), anti– nuclear antibody negative, C4 –⬍10 mg/dL (12–54), C3 –37mg/dL (85– 185), ENA I (Ro and La) negative, ENA II (Sm, SM Rnp) negative, p–ANCA negative, c–ANCA positive, lupus anticoagulant negative, anticardiolipin antibody negative, C–reactive protein 5.78 mg/dL (⬍0.8). Sural nerve biopsy: transmural chronic inflammatory infiltrates consistent with vasculitis. Pulse steroids and plasmapheresis were initiated without clinical improvement and worsening acidosis and on the 4th day she developed non–resuscitable ventricular tachycardia. A vasculitic process should be suspected in a patient with unexplained multi system involvement. Therapeutic interventions such as plasmapheresis and steroids should be initiated early.

498 SPONTANEOUS CURE, FOLLOWED BY FATAL COMPLICATION IN A PATIENT WITH RECURRENT PANCREATIC PSEUDOCYST Rajeev Jayadevan, M.D., Mario Ricci, M.D., Nejat Kiyici, M.D., Hilary Hertan, M.D., Capecomorin Pitchumoni, M.D.* and Stanley Oiseth, M.D. Gastroenterology, Our Lady of Mercy Medical Center, Bronx, NY and Pathology, Our Lady of Mercy Medical Center, Bronx, NY. Purpose: Pancreatic pseudocyst, a complication of pancreatitis, can have varied natural history. We report the case of a 60 year– old African American man with longstanding history of chronic pancreatitis secondary to alcohol abuse who had unusual complications from recurrent pseudocyst formation. Pseudocyst was first diagnosed 18 years ago and he had cystojejunostomy. He presented 11 months ago with upper abdominal fullness and anorexia, without abdominal pain. A large 12 cm loculated pseudocyst in the upper abdomen was found, and spontaneously disappeared in six weeks of close follow– up with complete resolution of symptoms. The patient, however, continued alcohol abuse. On readmission two weeks ago with abdominal pain and chest discomfort, examination revealed a wasted–looking man in some distress. Vital signs were: P–98/min, BP–120/80 mm Hg, RR–15/min, T–100.6 °F. Abdomen was soft and tender, with normal bowel sounds. Chest examination showed equal air entry with a few crackles in the bases. Labs: Amylase–570 U/L, Lipase–59 U/L, CBC–normal, LFT–normal, glucose–174 mg/dl, electrolytes and renal function–normal. Initial CXR showed infiltrates in the lung bases. CT scan showed a pseudocyst extending from the level of the pancreas upward into the thorax to the subcarinal region, compressing the lower esophagus. On the second day, he became acutely short of breath, requiring ventilatory support. Repeat CXR showed a large left–sided pleural effusion. Thoracentesis was performed, and a chest drain inserted. Pleural fluid analysis revealed amylase level of 26,087 U/L and lipase level of 16,898

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U/L, WBC count of 287 /␮l and RBC count of 2000 /␮l. He succumbed to his illness on the following day. Autopsy showed massive necrosis of the left lung from a ruptured pseudocyst in the thoracic cavity. Section of the pancreas revealed grossly dilated pancreatic ducts plugged with thick pasty greenish material. Discussion: Spontaneous resolution of pseudocyst occurs as a result of rupture into the pancreatic duct, adjacent viscera and pleural or peritoneal cavities. Rupture of a pseudocyst into the pleural cavity can lead to massive lung necrosis and death.

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granulomas. In the operating room, a large inflammatory mass was found in the mid–sigmoid with impressive dilation of the colon proximally. Resection of the sigmoid revealed a perforated diverticulum with surrounding inflammatory mass. After an uneventful post– operative course, the patient was discharged home. A repeat colonoscopy three months post discharge revealed near resolution of the aphthous lesions without any pharmacological intervention. Thus, we report a case of a young patient with diverticulitis and aphthous ulcers of the colon with no current clinical or pathological evidence of Crohn’s disease.

499 USE OF A FAMILY PRACTITIONER TO HEAD A TEAM EVALUATING AND TREATING A LARGE GROUP OF HEPATITIS C PATIENTS Richard P. Permutt, M.D.*. Gastroenterology, Kaiser Permanente, Santa Rosa, CA. Purpose: To ease the load of Hepatitis C on gastroenterologists in a managed care setting, a family practioner , under the guidance of the GI department, was utilized to oversee evaluation, management and treatment of Hepatitis C patients Methods: Using a team approach under protocol designed by a gastroenterologist but made up of a family practitioner, nurse pratitioner, and LVN, over 100 patients were recently taught in groups about Hepatitis C and treatment and evaluated for peg combo treatment. Biopsies were ordered and lab and treatment initiated and monitored by the team. Minimal gastroenterology consultation was required except in difficult cases. All degrees of disease were accepted including stable cirrhotics. Results: Compliance and acceptance by patients has been outstanding despite minimal gastroenterologist interaction.The addition of the family practitioner has added support to the psycho–social needs of the patients. No serious complications have occurred. The gastroenterology department has had much more time to spend on other aspects of their busy pracrices Conclusions: A team approach to treating Hepatitis C led by a family practioner creates efficiency in a busy gastroenterology practice unburdening the gastroenterologists while allowing their patients to be well cared for 500 APHTHOUS COLITIS IN A YOUNG PATIENT WITH DIVERTICULITIS Barbara H. Jung, M.D., John Carethers, M.D. and John J. Garvie, M.D.*. Gastroenterology, University of California, San Diego, CA. Purpose: Mechanical bowel obstruction in a young patient without a surgical history most commonly is due to stricture formation in Crohn’s disease, and can be the presenting symptom. Endoscopic features of Crohn’s disease bowel include inflammatory changes such as aphthous ulcers, “skipped” lesions and cobblestoning, and are accompanied by typical findings of IBD on pathology. To our knowledge, none of these endoscopic findings have been described with diverticulitis, a common disease of older adults. We describe the case of a 22 y.o. Hispanic male with no previous medical or surgical history who presented to our service with a one month history of progressive abdominal distension accompanied by intermittent abdominal pain, and loose bowel movements. On exam, the patient was afebrile with stable vital signs. He weighed 320 lbs., was alert and oriented, but in mild distress. His abdomen was markedly distended and diffusely tender to palpation but without peritoneal signs. Bowel sounds were present but hypoactive. Laboratory values of note included a WBC of 10.5 with a mild left shift. An abdominal CT revealed obstruction of both the large and small bowel with a stricture in the sigmoid colon. A colonoscopy revealed asigmoid stricture as well as diffuse aphthous ulcerations in the ascending, transverse as well as descending colon (see Figure) interspersed with normal appearing mucosa. The terminal ileum was unremarkable. Biopsies of the aphthous lesions were notable only for non–specific inflammation and no

501 LACK OF RESPONSE TO INFLIXIMAB AS TREATMENT FOR PREVENTING COLECTOMY IN PATIENTS WITH SEVERE ULCERATIVE COLITIS: A REPORT OF TWO CASES Alberto Unzueta, M.D., Jesus K. Yamamoto, M.D. and Luis F. Uscanga, M.D.*. Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion– Salvador Zubiran, Mexico D.F., Mexico. Background: In several pilot studies infliximab has been proven effective in the treatment of moderate to severe ulcerative colitis (UC). Although the majority of reports support the drug’s efficacy, there are few that refute its utility. Case Reports: Case 1– A 26 year old Hispanic male with 4 year history of UC (pancolitis) initially treated with sulfasalazine 3 g QD. He remained asymptomatic for 3 years until one week before his admission where he began to experience abdominal pain, and 8 to 10 bloody bowel movements a day accompanied with fever. Upon admission the patient was dehydrated and tachycardic, his hemoglobin and hematocrit were 6.3 g/dL and 19.8% respectively, WBC count of 10,000/mm3, albumin of 1.4 g/dL. Initial treatment consisted of PRBC transfusions, IV hydrocortisone (100 mg TID) and sulfasalazine 4.5 g QD and total parenteral nutrition. Due to lack of improvement after treatment with IV hydrocortisone for 7 days, the patient was given a single infusion of infliximab (5 mg/Kg). Clinical progress of the patient a week later was favorable with reduction in the number of bowel movements and overall clinical improvement. However in the following three weeks the number of bowel movements increased to 4 to 5 times a day and the patient experienced episodes of bowel suboclusion that resolved with medical treatment. By the fourth week after treatment with infliximab the patient was diagnosed with toxic megacolon and colonic perforation, requiring total colectomy and ileostomy. Case 2– A 33 year old Hispanic male with 5 year history of ulcerative colitis (pancolitis), treated with sulfasalazine 3 g QD followed by mesalamine (Asacol) 1.2 g QD. Three weeks before his admission he experienced 8 to 10 bowel movements a day, accompanied with abdominal pain and fever, prednisone 30 mg PO was added to his treatment. Upon admis-