The outcomes and optimal management of cirrhotic patients who develop cryptococcosis before transplantation are not fully known.We conducted a multicenter study involving consecutive patients with cirrhosis and cryptococcosis between January 2000 and March 2014. Data collected were generated as standard of care.In all, 112 patients were followed until death or up to 9 years. Disseminated disease and fungemia were present in 76.8% (86/112) and 90-day mortality was 57.1% (64/112). Of the 39 patients listed for transplant, 20.5% (8) underwent liver transplantation, including 2 with active but unrecognized disease before transplantation. Median duration of pretransplant antifungal therapy and posttransplant therapy was 43 days (interquartile range, 8-130 days) and 272 days (interquartile range, 180-630 days), respectively. Transplantation was associated with lower mortality (P = 0.002). None of the transplant recipients developed disease progression during the median follow-up of 3.5 years with a survival rate of 87.5%.Cryptococcosis in patients with cirrhosis has grave prognosis. Our findings suggest that transplantation after recent cryptococcal disease may not be a categorical exclusion and may be cautiously undertaken in liver transplant candidates who are otherwise deemed clinically stable.
Purpose: Pancreatic cancer is the fourth leading cause of cancer death in the U.S. and leads to an estimated 22 7,000 deaths per year worldwide. Majority of pancreatic cancer are adnocarcinoma which account 96% of cases with remaining 4% are indolent neuroendocrine tumors. Pancreatic neuroendocrine tumors (PNETs) are uncommon tumors which arise from endocrine cell of the pancreas. We report a case of coincidence of neuroendocrine tumor at the tail of pancreas and adenocarcinoma of the body of pancreas in an elderly patient, which we believe that a rare synchronous finding. Case: An 81 year-old man was admitted to the hospital for evaluation of three months history of weakness, upper abdominal pain, watery diarrhea and 20 lbs weight loss. Past medical and surgical history significant for diabetes, hypertension, coronary artery disease and inguinal hernia repair. He is a former smoker of 1 pack per day for approximately 20 and had no history of alcohol use. Physical examination was unremarkable. Liver function tests revealed Total Bilirubin of 0.7 mg/dl Alkaline phosphatase of 219 U/L, Alanine aminotransferase of 104 U/L and Aspartate aminotransferase of 62 U/L. Ultrasound of the abdomen showed mass in the mid body of the pancreas measured 30.1 x 30 x 40 mm in size. Computed tomography showed two masses in the pancreas. The first mass located at the mid body of the pancreas and was large, bi-lobed and the entire size of the mass measured 55.7 x 50.6 mm. The second mass was rounded and located at the distal tail of the pancreas, close to the spleen and measured 20.8 x 26.4 mm. The endosonographic examination of the pancreas was performed and revealed a large bi-lobed pancreatic body mass. The right lobe of the mass measured 29.5 x 32.8 mm and was hypoechoic, round and obstructed the pancreatic duct and invaded the splenic artery. The left lobe of the mass measured 36.4 x 43.5 mm and was hypoechoic, heterogeneous with an anechoic, necrotic center. Fineneedle aspiration with 25 gauge needle of both lobes of the mass was performed. The second pancreatic mass was seen at the tail of the pancreas measuring 20.6 x 18.9 mm. The mass was hypoechoic, round and had a well demarcated boarder. Fine needle aspiration was performed using a second 25 gauge needle. The results of fine needle aspirations of the pancreatic body and tail masses revealed moderately differentiated adenocarcinoma and neuroendocrine tumor respectively. Conclusion: Coexistence of adenocarcinoma and neuroendocrine neoplasm of the pancreas is a rare entity. The findings of more than one pancreatic mass, as in our patient, may prompt an EUS with FNA of each of the masses to make the definite diagnosis of potential coexisting neoplasms.
Characteristics of cirrhosis-associated cryptococcosis first diagnosed after death are not fully known. In a multicenter study, data generated as standard of care was systematically collected in 113 consecutive patients with cirrhosis and cryptococcosis followed for 80 patient-years. The diagnosis of cryptococcosis was first established after death in 15.9% (18/113) of the patients. Compared to cases diagnosed while alive, these patients had higher MELD score (33 vs. 22, P = .029) and higher rate of cryptococcemia (75.0% vs. 41.9%, P = .027). Cases diagnosed after death, in comparison to those diagnosed during life were more likely to present with shock (OR 3.42, 95% CI 1.18–9.90, P = .023), require mechanical ventilation at admission (OR 8.5, 95% CI 2.74-26.38, P = .001), less likely to undergo testing for serum cryptococcal antigen (OR 0.07, 95% CI 0.02–0.21, P < .001) and have positive antigen when the test was performed (OR 0.07, 95% CI 0.01–0.60, P = .016). In a subset of cirrhotic patients with advanced liver disease cryptococcosis was first recognized after death. These patients had the characteristics of presenting with fulminant fungemia, were less likely to have positive serum cryptococcal antigen and posed a diagnostic challenge for care providers.
Purpose: This is the case of a 75 year-old male patient who presented after the incidental finding of a 90 mm cyst adjacent to the tail of the pancreas, which was found during a computed tomography (CT) angiogram ordered for evaluation of abdominal aortic aneurysm grafting. The patient had no history of acute or chronic pancreatitis, nor any history of alcohol abuse, or significant abdominal trauma. The initial differential diagnosis included cystic neoplasm and pseudocyst. A magnetic resonance cholangiopancreatography (MRCP) was performed and revealed a 90 mm cyst with a solid component adjacent to the tail of the pancreas. The patient was referred for endoscopic ultrasound and fine needle aspiration (EUS-FNA) which revealed a hypoechoic, heterogeneous, pancreatic cystic mass in the region of the tail of the pancreas, measuring 95.3 mm x 53.7 mm. The border was poorly demarcated and was abutting the spleen. The microscopic examination of the FNA sample revealed necrotic debris with rare clusters of columnar epithelial cells, with no evidence of malignancy. However, no definitive diagnosis could be made. The Patient was referred to surgery and distal pancreatectomy with splenectomy was performed. Pathology revealed a cystic lesion, which was lined by keratinizing squamous epithelium overlaying lymphoid tissue made up of small to medium sized lymphocytes with germinal center formation, consistent with a lymphoepithelial cyst. The postoperative period was complicated by the development of a paripancreatic abscess, which was treated by percutaneous drainage and antibiotics. The recovery was then uneventful. This case demonstrates that while it may be true that the majority of cystic lesions in and around the pancreas are pseudocysts or cystic neoplasms, there are a number of rare and benign conditions that present in similar fashion, including pancreatic lymphoepithelial cysts. Despite the increasing availability of high quality CT scans and MRIs, as well as the evolution of endoscopic ultrasound, which make the diagnosis of pancreatic cystic masses more readily prior to surgeries, the diagnosis of lymphoepithelial cysts still represents a true challenge due to a spectrum of nonspecific imaging and serological findings, making its differentiation from cystic neoplasms difficult. Hence surgery is still considered, in certain circumstances, for definitive diagnosis.
