Common bile duct stenosis with hypereosinophilia and pancreatitis in childhood: report of 2 cases

Eosinophilic pancreatitis: a review of the pathophysiology, diagnosis, and treatment

Eosinophilic pancreatitis (EP) is an extremely rare disease caused by purely eosinophilic infiltration of the pancreas. EP is prone to being misdiagnosed as pancreatic cancer, causing unnecessary economic and physical harm to the patient. We report three cases of EP that were cured by steroids without relapse from 2017 to now. The clinical data of the three patients, including clinical manifestations, serological manifestations, imaging (ultrasound, computed tomography, and MRI), pathological diagnosis and treatment, and telephone follow-up of all patients, were retrospectively analysed. In addition, a literature search was conducted on the Web of Science and PubMed databases using key terms related to EP, considering case reports with no restrictions on the date of publication or language. In conclusion, we analysed 19 cases and determined the diagnostic criteria for EP. The diagnostic algorithm for EP can be used to diagnose EP easily. We hope that our standards and algorithm can reduce the rate of misdiagnosis and contribute to clinical diagnosis and treatment. In addition, we expect to evaluate more EP cases to test our diagnostic criteria and design a systematic diagnostic flow chart.

Eosinophilic Pancreatitis Diagnosed With Endoscopic Ultrasound

Eosinophilic pancreatitis (EP) is a rare clinical entity, and few cases have been reported. It usually presents on imaging as a pancreatic mass leading to common bile duct obstruction and jaundice. Since it can mimic a malignancy, eosinophilic pancreatitis is often diagnosed after “false positive” pancreatic resections. To our knowledge, we report the only known case of EP in which the diagnosis was made by fine needle aspiration and core biopsy of the pancreas during EUS, sparing the patient a surgical resection. After a steroid course, there was improvement of clinical symptoms.

Allergic manifestations in autoimmune pancreatitis

OBJECTIVE

Autoimmune pancreatitis (AIP) is a peculiar type of pancreatitis of presumed autoimmune etiology. However, target antigens for AIP have not been detected. Furthermore, its preponderant occurrence in elderly men and the very dramatic response with no major residual deformity to oral steroid therapy within 2 weeks suggest that the pathogenesis of AIP might not involve autoimmune mechanism. Recently, it was reported that the immune reaction closely involved in the pathogenesis of allergic disorders was upregulated in the affected tissues of AIP. This study aimed to examine the allergic manifestations in AIP patients.

METHODS

This case series consisted of 45 AIP patients. Present and/or past histories of allergic diseases, clinical findings, and laboratory data were reviewed.

RESULTS

Twenty patients (allergic-type AIP) had histories of allergic diseases, such as acute allergic rhinitis (n= 11), including rose and hay fever, atopic dermatitis (n= 5), bronchial asthma (n= 3), drug allergy (n= 2), and hypersensitivity pneumonitis (n= 1). Serum IgE levels were elevated in only 12 allergic-type AIP patients, and they were significantly higher in allergic-type AIP patients than in AIP patients without allergic manifestations (P = 0.0001). The peripheral eosinophil count was significantly elevated in allergic-type AIP patients (P =0.048). With respect to initial symptoms, obstructive jaundice was less frequent in allergic-type AIP patients (P = 0.012), and abdominal pain was detected in only five patients with allergic-type AIP (P = 0.013). Allergic-type AIP occurred predominantly from September to February in 19 of 20 patients (P = 0.001).

CONCLUSION

Allergic manifestations were detected in about half of the AIP patients, and allergic mechanisms may be related to the occurrence of AIP in these patients.

Eosinophilic pancreatitis and increased eosinophils in the pancreas

Prominent eosinophilic infiltrates are an unusual finding in the pancreas. Eosinophilic pancreatitis is one rare etiology of pancreatic eosinophilia, but other described causes of eosinophilic infiltrates have also included pancreatic allograft rejection, pancreatic pseudocyst, lymphoplasmacytic sclerosing pancreatitis (LPSP), inflammatory myofibroblastic tumor, and histiocytosis X. In this study we describe the clinicopathologic features of three new cases of eosinophilic pancreatitis and conduct a retrospective 18-year institutional review of the myriad disease processes associated with pancreatic eosinophilia. In the files of the Johns Hopkins Hospital, <1% of all pancreatic specimens had been noted to show increased numbers of eosinophils. Eosinophilic pancreatitis itself was a rare etiology for pancreatic eosinophilia, with only one in-house case over the 18-year study period and two additional referral cases. Other disease processes associated with prominent eosinophilic infiltrates were more common and included pancreatic allograft rejection (14 cases), LPSP (5 of 24 total LPSP cases evaluated), inflammatory myofibroblastic tumor (4 cases), and systemic mastocytosis (1 case). Patients with eosinophilic pancreatitis showed two distinct histologic patterns: 1) a diffuse periductal, acinar, and septal eosinophilic infiltrate with eosinophilic phlebitis and arteritis; and 2) localized intense eosinophilic infiltrates associated with pseudocyst formation. All three patients with eosinophilic pancreatitis had peripheral eosinophilia, and all had multiorgan involvement. One patient with LPSP also had marked peripheral eosinophilia, and 5 of 24 LPSP cases demonstrated prominent eosinophilic infiltrates in the gallbladder, biliary tree, and/or duodenum. Notably, not all of these patients with LPSP with prominent eosinophils in other organs had increased eosinophils in the pancreas itself. These results emphasize the infrequent nature of pancreatic eosinophilia and its multiple potential disease associations. True eosinophilic pancreatitis, although a fascinating clinicopathologic entity, is one of the rarest causes of pancreatic eosinophilia.