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.