Case 1
A 72-year-old male patient with co-morbids including diabetes mellitus,
ischemic heart disease and benign prostatic hyperplasia came to our
hospital with complaints of yellow discoloration of sclera, dark colored
urine, and pale colored stools for 15 days. Patient history included
coronary artery bypass grafting (18 years ago) and carotid
endarterectomy (19 years ago). On arrival the patient was stable except
having jaundice. CT scan abdomen with contrast showed heterogeneous
appearing lesion involving the uncinate process of the pancreas likely
representing a neoplastic lesion (Figure 1 ). Few small
pulmonary pleural based soft tissue density nodules were also noted
suspicious for metastatic deposits. His blood CA19-9 was 42.07 U/mL
(Normal: non-detectable to 39 U/mL). PET-CT showed low FDG avid soft
tissue lesion involving uncinate process of pancreas and non-FDG avid
predominantly sub pleural subcentimeter bilateral lung nodules.
Post-procedure, the patient was shifted to intensive care unit for
post-surgical care. He became hypotensive therefore was kept on dual
inotropic support. Patient had raised troponin level of 25 and developed
atrial fibrillation. He was managed with intravenous fluids, analgesics,
antibiotics, Vitamin K, Amiodarone, and anti-emetics. Chest x-ray
revealed left sided pleural effusion which was aspirated under
ultrasound guidance. His Jackson Pratt drain was removed on 9th
post-operative day. Patient had complaints of bloating and abdominal
pain, therefore CT scan abdomen and pelvis with contrast was done, which
did not report any anastomotic leak or abdominal collection. His Jackson
Pratt drain was then removed on 9th post-operative day. He was
eventually mobilized out of bed. Incentive spirometry and chest
physiotherapy were done. His diet was progressed gradually which he
tolerated well. The patient was in stable condition at the time of
discharge. Serum IgG4 levels performed two days prior to discharge were
elevated at 2220 mg/L (39.2-864). Patient follow up CT scan abdomen
after one year was unremarkable. Serum IgG4 levels were 1470 mg/L.