A 66-year-old man presented to our hospital with fever and epigastralgia. He was treated with oral steroid therapy for 2 months prior to admission for renal failure caused by antineutrophil cytoplasmic antibody-associated vasculitis. Laboratory data showed elevated levels of amylase (499 IU/L; normal, 42-132 IU/L) and lipase (272 IU/L; normal, 13-49 IU/L). Computed tomography (CT) and magnetic resonance cholangiopancreatography showed enlargement of the head of the pancreas and dilatation of the main pancreatic duct (MPD). Esophagogastroduodenoscopy (EGD) showed erythematous and edematous major papilla (Fig. 1). A histopathological examination of biopsy specimens, taken from the major papilla, revealed active duodenitis, with a cytomegalovirus (CMV) infection confirmed by immunostaining (Fig. 2A). An examination for CMV antigenemia (C7-HRP) showed 63 positive cells per 50,000 cells (Fig. 2B). Based on these findings, the papillitis was determined to be caused by the CMV infection. After 1 month of treatment with intravenous ganciclovir, a CT scan showed that the dilatation of the MPD and enlargement of the head of the pancreas had improved; in addition, a repeat EGD indicated improvement in the edematous major papilla. Since then, symptoms related to pancreatitis have not recurred. Although CMV is a common opportunistic pathogen infecting patients taking immunosuppressive drugs, CMV-associated duodenal papillitis is rare [1-3]. The possibility of acute pancreatitis caused by CMV-associated duodenal papillitis should be considered among immunosuppressed patients.
Figure 1.
Endoscopic image showing an edematous major papilla
Figure 2.
Photomicrographs of the biopsy specimen taken from the major papilla. (A) A very small number of cytomegalovirus inclusions were seen (hematoxylin and eosin stain; original magnification, 400×). (B) The cells with cytomegalovirus inclusions showing positive immunoreactions to the presence of cytomegalovirus (original magnification, 400×)
Biography
National Hospital Organization, Osaka National Hospital, Osaka, Japan
Footnotes
Conflict of Interest: None
References
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