A 27-year-old woman with Crohn's disease, who had sustained clinical remission for two years following treatment with mesalazine and nutrition therapy, was admitted to our hospital complaining of dry cough, mild dysphagia, and slight fever. A computed tomography of the chest demonstrated an increase in the thickness of the tracheal wall. Bronchoscopy showed a diffusely erythematous and edematous mucosa with whitish granular lesions in the trachea and main carina. Bronchial biopsy specimens showed epithelioid cell granuloma. We diagnosed tracheobronchitis as an extraintestinal manifestation of Crohn's disease. She was treated with 40mg/day prednisolone. Her symptoms improved immediately. However, dry cough recurred two months after prednisolone treatment, and further treatment with inhaled steroids was prescribed. Tracheobronchial involvement in Crohn's disease is rare, with only 13 cases having been reported. Tracheal involvement should be considered in Crohn's disease patients with respiratory symptoms.
A 42-year-old man, who had stopped smoking almost one year ago, visited our hospital for hematochezia. He was diagnosed as having ulcerative colitis and was prescribed 5-amino salicylic acid and corticosteroids, which led to the remission of his disease. However, the disease relapsed after sufficient continuous corticosteroids administration and persisted despite 5-amino salicylic acid administration and intensive treatment with corticosteroids, immune modulators, leukocyte apheresis, and anti-TNF-α antibodies. Curiously, clinical remission was achieved after he resumed smoking, and colonoscopy revealed mucosal healing. Such remission may be attributable to anti-inflammatory effects of smoking nicotine and carbon oxides.
A 73-year-old man was incidentally diagnosed with a cystic lesion in the pancreatic body. Ultrasonography, abdominal computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound were performed, and a nodule was detected in the cystic lesion along with an irregularity of the main pancreatic duct. An initial diagnosis of a mixed-type intraductal papillary mucinous neoplasm was made, and a central pancreatectomy was performed. However, the final diagnosis was altered to non-invasive intraductal papillary mucinous carcinoma (IPMC). The histopathological examination revealed a fibrotic lesion that was similar to "tubular complex" findings observed in mouse models of pancreatic cancer. The fibrotic lesion was placed between the main pancreatic duct lesion and branch-duct cystic lesion. The changes reflected in branch-level stenosis may be caused by IPMC growth.
A 65-year-old male was referred to our hospital 2 years ago for a multilocular cyst accompanied with a protein plug in the pancreas tail. He was diagnosed as having branch duct-type intraductal papillary mucinous neoplasm and was followed-up. Two years later, endoscopic ultrasonography revealed a hypoechoic lesion, 10mm in diameter, near the cyst-like lesion. Finally, he was diagnosed with small pancreatic adenocarcinoma concomitant with intraductal papillary mucinous neoplasm and underwent radical distal pancreatectomy with splenectomy. Resected specimen revealed that the protein plug in the main pancreatic duct had caused distal pancreatic duct dilatation, resembling a multilocular cyst and pancreatic duct stenosis with inflammatory changes and fibrosis around the pancreatic parenchyma. Here, we report a rare case of protein plugs in the pancreatic duct mimicking pancreatic cancer concomitant with branch-type intraductal papillary mucinous neoplasm.
A 79-year-old male presented to our hospital with abdominal discomfort and was diagnosed with mass-forming pancreatitis. During follow-up, pancreatic stones and a hepatic mass with peripheral bile duct dilation were discovered. Serum IgG4 level was elevated, and a liver tumor biopsy revealed numerous IgG4-positive plasma cells and fibrosis. Chronic pancreatitis with the suspected involvement of autoimmune pancreatitis (AIP) and IgG4-related hepatic inflammatory pseudotumor (IgG4-HIP) was diagnosed. Therefore, a steroid treatment was initiated. However, 2 months later, the patient complained of epigastric pain that was found to be caused by an impacted pancreatic stone in the major papilla, which was endoscopically removed. Follow-up imaging findings confirmed the improvement in AIP and the dissolution of the IgG4-HIP.
A 78-year-old man with chief complaints of cough and lower limb numbness was admitted to our hospital. Serum myeloperoxidase-antineutrophil cytoplasmic antibody titer (MPO-ANCA) was elevated (48.8U/ml), and a diagnosis of microscopic polyangiitis (MPA) was made. After admission, the patient developed a fever and right upper quadrant pain. Ultrasonography and computed tomography revealed an acute cholecystitis of unknown cause, and laparoscopic cholecystectomy was performed. Histopathological examination of the resected gallbladder revealed necrotizing vasculitis along with the infiltration of eosinophils, lymphocytes, and plasma cells around the small arteries in the muscular layer of the gallbladder, which are characteristics of MPA.