American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Fulminant Emphysematous Pancreatic Pseudocyst: Infected with Normal Skin Flora

(A) Ultrasonography of the abdomen. Intra-abdominal pancreatic cyst (7 × 8 cm) with echogenic debris. (B) Axial; (C) Sagittal images: contrast-enhanced computed tomography. Complicated pseudocyst, compression of the common bile duct, and dilated biliary tracts.

A 49-year-old man was alcoholic and had major depressive disorder. He experienced epigastric pain, poor appetite, and weight loss for 1 month. Ultrasonography of the abdomen revealed a pancreatic cyst (7 × 8 cm) with echogenic debris (Figure 1A). Contrast-enhanced computed tomography (CT) of the abdomen showed a complicated pancreatic pseudocyst (Figure 1B), compressed common bile duct, and dilated biliary tracts (Figure 1C). Laboratory data revealed an amylase level of 59 U/L (normal range: 28-100 U/L), a lipase level of 175 U/L (normal range: 22-51 U/L), a white blood cell count of 10,700/µL (normal range: 4000-10,000/µL), and a C-reactive protein level of 12.7 mg/L (normal range: 0-5 mg/L). After 1 week of intravenous antibiotic treatment, his condition deteriorated, and he was referred to a medical center. In the emergency department, one episode of pulseless ventricular tachycardia was noted; his spontaneous circulation was restored after cardiopulmonary resuscitation. Follow-up CT showed emphysematous changes in the pancreatic pseudocyst, and percutaneous drainage of the abscess was performed under CT guidance by using a 10-Fr pigtail catheter (Figure 2A). Because pseudocyst rupture was suspected, a contrast medium was injected into the abscess cavity, and no leakage or fistula formation was observed (Figure 2B). Corynebacterium striatum was isolated from the drained pus but not from the patient’s blood. His condition improved, and he was discharged after treatment.

Discussion

C. striatum is an aerobic, gram-positive bacillus that ubiquitously colonizes the skin and mucous membranes of humans. Although it is isolated from cultures, C. striatum is generally considered a clinically nonsignificant contaminant. The number of studies reporting the pathogenicity of C. striatum has been increasing, particularly as a causal agent of nosocomial infections such as intravascular catheter-associated septicemia, native and prosthetic valve endocarditis, device-related infections, peritonitis in peritoneal dialysis patients, meningitis, pulmonary abscess, and septic arthritis in hospitalized and immunocompromised patients.1 Reports of true infection are confirmed by isolation of C. striatum from a sterile site and the presence of clinical symptoms and signs. C. striatum was reported to exhibit susceptibility to vancomycin, linezolid, and daptomycin; however, many isolates were reported to exhibit multidrug resistance.2

Indications for pancreatic pseudocyst drainage include persistent pain attributable to the fluid collection, gastric or duodenal obstruction, biliary obstruction, development of pancreatic ascites or pleural effusion, pancreatic enlargement on serial imaging, and signs of pseudocyst infection or bleeding.3 If the pseudocyst communicates with the main pancreatic duct, endoscopic transpapillary drainage with placement of a pancreatic duct stent is suggested.4 An increasing number of studies have suggested routine transmural drainage use, particularly when transpapillary drainage fails. The advantage of transpapillary drainage over transmural drainage is the avoidance of bleeding or perforation. However, pancreatic stents may induce scarring of the main pancreatic duct. Laparoscopic and open pancreatic cystogastrostomy both have equal success rates compared with endoscopic drainage, but endoscopic drainage is associated with shorter hospital stays and lower cost than laparoscopic and open pancreatic cystogastrostomy. Percutaneous drainage has a lower overall success rate, higher complication rate, and higher mortality risk than surgical drainage.5 However, percutaneous drainage is preferred for pancreatic fluid collection that is not adjacent to the gastrointestinal lumen or does not communicate with the pancreatic duct, particularly in patients who have immature infected pseudocysts or those who are ineligible candidates for surgery. In conclusion, if the signs or symptoms of pancreatic pseudocysts exhibit indications for drainage requirement, aggressive treatment should be provided to prevent fulminant sequelae, particularly in immunocompromised and patients with alcoholism.

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– Chih-Wen Wang, MDa,b, Chia-Yen Dai, MD, PhDb, Tzer-Ming Chuang, MDb, Chung-Feng Huang, MD, PhDb, Ming-Lun Yeh, MDb, Ching-I Huang, MDb, Zu-Yau Lin, MD, PhDb, Shinn-Cherng Chen, MD, PhDb, Jee-Fu Huang, MD,PhDb, Ming-Lung Yu, MD, PhDb, Wan-Long Chuang, MD, PhDb

-This article originally appeared in the February issue of The American Journal of Medicine.

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