Pancreatic abscess associated with Achromobacter group Vd biovar 1.

A case of pancreatic abscess associated with Achromobacter biovar 1 in a 75-year-old man with multiple predisposing debilitating conditions is presented. The infection responded to antibiotic therapy, but the patient died from unrelated causes.     

Pancreatic abscess caused byClostridium difficile

The first known case of pancreatic abscess caused byClostridium difficile in a patient with no history of diarrhea or previous antibiotic therapy is presented. After surgical intervention and antibiotic therapy with metronidazole (500 mg every 8 h) and cefotaxime (1 g every 8 h) the patient recovered completely.     

Anatomical features of the minor duodenal papilla in pancreas divisum

Background Clinical expression of pancreas divisum is often explained as a consequence of relative or true stenosis of the minor papilla with dorsal duct obstruction. This anatomo-functional study of the minor papilla in pancreas divisum has included its topographical, functional and structural features.Materials and methods The study was carried out on 37 human autopsy specimens of duodenopancreas, which underwent pancreatography, manometrically controlled perfusion and light microscopy.Results One pancreas divisum was detected in the study group. In this case, the distances between the minor and the major papilla was 24.0 mm, and between the minor papilla and the superior duodenal flexure 27.4 mm. The minor papilla was patent when perfused under pressure of 10 mmHg, and its light microscopy revealed regular global histological organization with only light fibrosis and no cellular atypia.Conclusions The structure and position of the minor papilla in pancreas divisum did not significantly differ from the ones in fused pancreases.     

A case of santorinicele without pancreas divisum: diagnosis with multi-detector row computed tomography

A santorinicele is defined as a focal cystic dilatation of the terminal portion of the dorsal pancreatic duct at the minor papilla. Most cases reported previously were associated with pancreas divisum and a santorinicele without pancreas divisum is known to be rare. We recently experienced a typical case of a santorinicele without pancreas divisum in a 67-yr-old woman with abdominal pain and hematochezia, subsequently proven to be the result of an ischemic colitis. The santorinicele was diagnosed incidentally with multi-detector row computed tomography using a minimum intensity projection technique, which clearly showed a cystic dilatation of the terminal portion of the dorsal pancreatic duct and a communication between the ventral and dorsal pancreatic ducts. This finding was also confirmed by a magnetic resonance cholangiopancreatography.     

Pancreatic abscess caused by s. typhi

A case of pancreatic abscess due to Salmonella typhi in a 40-year-old male is presented. The patient was managed by percutaneous needle aspiration and antibiotic therapy.     

Pancreatic polypeptide cell hyperplasia of the pancreas

A case of pancreatic polypeptide cell hyperplasia in a 76-year-old man who presented with subacute bowel pseudo-obstruction is reported. A computed tomography scan incidentally showed a pancreatic head lesion that was resected by pancreaticoduodenectomy. Histological examination showed expansion of the endocrine pancreas with increased numbers of pancreatic polypeptide cells in irregularly enlarged islets, ragged endocrine cell clusters, ductulo-insular complexes and microadenomas. The clinicopathological features of this rare and poorly understood condition are discussed.     

Pancreatic endocrine tumours associated with WDHA syndrome

Summary Nine pancreatic endocrine tumours of patients with watery diarrhoea hypokalaemia achlorhydria (WDHA) syndrome were examined by immunohistochemistry and electron microscopy. All cases revealed neoplastic proliferation of VIP (vasoactive intestinal peptide)-immunoreactive (IR) cells. Immunoreactivity to a novel peptide hormone PHM-27, which is processed from a common big precursor peptide of VIP (prepro VIP/PHM-27), was identified in VIP-IR cells of 8 tumours. VIP-PHM-IR cells had secretory granules measuring about 130 to 220 nm in diameter. Radioimmunoassay of tumour tissue extracts showed high VIP and PHM contents in proportional amounts in most cases. According to the results of immunostaining, the 8 tumours fell into two large groups; 5 with PP (pancreatic polypeptide)-IR cells and 3 with CT (calcitonin)-IR cells. The former group demonstrated VIP cells and PP cells intermingled in various proportions, including one tumour in which coexistence of PP-IR and VIP-IR in the same cells was demonstrated. Cell heterogeneity of the tumours and possible relationships of VIP, PP and CT cells were discussed.This work was supported in part by Grants-in-Aid for Cancer Research from the Ministry of Health and Welfare and from the Ministry of Education, Science and Culture, Japan     

Brain abscess associated with multidrug-resistant Capnocytophaga ochracea infection

Brain abscesses are occasionally associated with a dental source of infection. An unusual case of frontal lobe abscess in a nonimmunocompromised child infected with multidrug-resistant Capnocytophaga ochracea is described and confirms the pathogenic potential of this organism to cause human disease in the central nervous system.     

Pancreatic pseudotumors: non-neoplastic solid lesions of the pancreas that clinically mimic pancreas cancer

In the pancreas, a variety of non-neoplastic conditions may form solid masses that may mimic cancer. Up to 5% of pancreatectomies performed with the preoperative clinical diagnosis of carcinoma will prove to be non-neoplastic by pathologic examination, although this figure is decreasing with improved diagnostic modalities. Chronic inflammatory lesions are the leading cause of this phenomenon ("pseudotumoral pancreatitis"), and among these, autoimmune and paraduodenal pancreatitides (discussed separately in this issue) are most important. In this article, we will focus on the noninflammatory lesions that may form tumor-like lesions of the pancreas. Adenomyomatous hyperplasia of ampulla of Vater is a subtle lesion that is difficult to define; larger examples (>5 mm) have been found to be the cause of obstructive jaundice. Accessory (heterotopic) spleen may form a well-defined nodule within the tail of the pancreas and is typically mistaken for endocrine neoplasm. Lipomatous hypertrophy is the replacement of pancreatic tissue with mature adipose tissue that occasionally leads to moderate to marked enlargement of the pancreas. Hamartomas are very rare if the entity is defined strictly. They are characterized by irregularly arranged mature pancreatic elements admixed with stromal tissue. A cellular, spindle-cell variant with c-kit (CD117) expression is recognized. Pseudolymphoma forms well-defined nodules composed of hyperplastic lymphoid tissue. Rarely, foreign-body deposits, granulomatous inflammations (such as sarcoidosis or tuberculosis), and congenital lesions may form tumoral lesions. In conclusion, it is important to recognize the types of conditions that form pseudotumors in the pancreas so that they can be distinguished from ductal adenocarcinomas, especially clinically, but also pathologically. Nonspecific terms such as "inflammatory pseudotumor" ought to be avoided, and every attempt should be made to classify a "pseudotumor" into a more specific diagnostic category discussed above.     

Pancreatic fibrosis associated with age and ductal papillary hyperplasia

Little is known about the frequency, type and pathogenesis of fibrotic changes that may occur in the pancreas of persons without any clinically apparent or macroscopically visible pancreatic disease. We screened pancreas specimens for the presence and pattern of fibrosis, determined the relationship between fibrosis, age, and duct lesions, and studied the fibrogenic mechanisms. In 89 postmortem specimens from persons without any known pancreatic disease (age range 20–86 years), fibrosis was recorded and graded and the patients were divided into two age classes (younger or older than 60 years). In addition, we analyzed the association between ductal papillary hyperplasia [i.e., pancreatic intraepithelial neoplasia type 1B (PanIN-1B)] and fibrotic foci in the pancreatic tissue to determine the potential impact of obliterating duct lesions on pancreatic fibrosis. Finally, we studied the occurrence in the pancreas of myofibroblasts, identified on the basis of their α-SMA and desmin positivity, and determined their relationship to the fibrotic foci. Thirty-eight (44%) of 89 pancreata showed scattered foci of lobular fibrosis affecting peripheral lobuli. Fibrotic changes were significantly more common in individuals older than 60 years. Fibrotic foci were commonly associated (p<0.05) with ductal papillary hyperplasia in ducts draining fibrotic lobuli. Myofibroblasts were detected in the fibrotic foci. The “normal” pancreas develops a specific type of focally accentuated fibrosis that is highly age related. This patchy lobular fibrosis in the elderly (PLFE) was closely associated with PanIN-1B lesions in the ducts, suggesting that the narrowing of a duct due to papillary hyperplasia of the epithelium may hamper secretion and cause fibrosis of the drained lobule. The presence of myofibroblasts in association with the fibrotic foci indicates an ongoing fibrogenic process.     

Pancreas divisum inversus

Pancreatic duct variations are usually diagnosed incidentally, in particular when using magnetic resonance cholangiopancreatography (MRCP), the most accurate imaging modality for depicting the pancreatic ductal system. However, the frequency and the embryologic development of pancreatic variants have not been well investigated. The purpose of this prospective study was to investigate the frequency of pancreatic ductal variants, providing potential explanations of their embryologic basis. The pancreatic ductal anatomies of 202 patients with mean ± standard deviation (SD) age of 54 ± 27 years, 56% females, who underwent MRCP for different indications between April 2018 and March 2019, were prospectively collected. Normal pancreatic ductal variants were identified in 196 cases (97%), and variants of pancreas divisum in six cases (3%). In the type C variant of the normal pancreatic anatomy, found in 3% of the cases, the dorsal duct was joined to the ventral duct while the accessory duct did not communicate with the dorsal duct. Unlike the classic type C variant, in our cases, the accessory pancreatic duct (APD) was long (mean ± SD of 58 ± 8.5 mm) and originated in the lower portion of the pancreatic head, caudally to the duct of Wirsung. This was a new subtype of the type C variant or a new variant, which could be called “pancreas divisum inversus”; the APD could be called the isolated duct of Santorini. Reporting this new variant could increase knowledge regarding the pancreatic anatomy in order to avoid misdiagnosis and to help in better understanding pancreatic diseases and their relative treatment. Clin. Anat., 33:646–652, 2020. © 2019 Wiley Periodicals, Inc.     

Os parietale divisum

Divisions of the parietal bone are extraordinarily rare, and have been described previously only in skull specimens in the anatomical literature. We report a case of os parietale divisum (divided parietal bone) in an infant with plagiocephaly. A 36-weeks gestation male with multiple congenital anomalies presented to the deformational plagiocephaly clinic at 11 weeks of age. CT imaging demonstrated a suture dividing the left parietal bone into two segments. He had a plagiocephalic appearance, with the greater occipital and parietal protuberances ipsilateral to the abnormal left parietal suture, and a correspondingly flatter right occiput. Head circumference was in the normal range, and the anterior fontanelle was patent and of normal size. He had mild right-sided right frontal and malar protuberance. Mandibular asymmetry was noted with a chin-point to the right of midline. He had a left-sided head tilt. He was treated with cranial molding helmet therapy for his head shape and physical therapy for his head tilt. After 16 months of helmet therapy, he had little improvement of his head shape. This case is an in vivo presentation of a rare variant, os parietale divisum.