Presse Med. 2015; 44: 572–573

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Emphysematous pancreatitis. A rare cause of fulminant multiorgan failure Brice Robert, Cyril Chivot, Thierry Yzet

Available online: 18 December 2014

Amiens North Hospital, Department of Digestive and Abdominal Radiology, Diagnostic Imaging, 80054 Amiens cedex 01, France

Correspondence: Brice Robert, University of Picardy, Amiens North Hospital, Department of Digestive and Abdominal Imaging, diagnostic radiology, place Victor-Pauchet, 80054 Amiens cedex 01, France. [email protected]

Pancréatite emphysémateuse. Une cause rare de défaillance multiviscérale

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55-year-old man was admitted in our institution for acute pulmonary distress. His medical history past included inferior myocardial infarction and hypercholesterolemia. There was no history of chronic or acute pancreatitis. At the admission, the patient was cyanotic and unconscious. He needed quickly mechanical ventilatory support, vascular filling and intravenous injection of vasoactive drugs. Clinical examination found major abdominal distension and diffuse defense. No bruising skin was found on the abdominal wall. Initial laboratory results showed many biological abnormalities such as leukopenia (900/mm3), thrombocytopenia (67,000/mm3), elevated C-reactive protein (73 mg/mL), metabolic acidosis (pH: 6.93) with elevated blood lactate (15 mmol/L), severe renal dysfunction with estimated creatinine clearance less than 15 mL/min and hyperlipasemia (1335 U/L). The initial suspected diagnosis was acute mesenteric infarction. Therefore, contrast enhanced computed tomography (CT) was performed and showed the presence of gas in the pancreatic bed, in the retroperitoneal spaces and into the main pancreatic duct (figure 1). Mesenteric vessels were permeable and there was no sign of bowel infarction. Pancreatic enhancement was normal without peripancreatic fluid collection found. The diagnosis of fulminant emphysematous pancreatitis with multiorgan failure was finally retained. After two hours in the intensive care unit and despite intensive treatment, the evolution was quickly fatal. Blood cultures came back positive for Enterobacter aerogenes.

tome 44 > n85 > mai 2015 http://dx.doi.org/10.1016/j.lpm.2014.06.024 © 2014 Elsevier Masson SAS. All rights reserved.

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Emphysematous pancreatitis. A rare cause of fulminant multiorgan failure

Figure 1 Axial (A) and coronal (B) computed tomography views showing the presence of air bubbles within and around the pancreatic parenchyma (white arrows) but also into the main pancreatic duct (white arrowhead)

Comments Emphysematous pancreatitis is a rare and life-threatening form of acute pancreatitis occurring mostly in debilitated patients with mellitus diabetes, chronic kidney disease, cardiovascular disease or others causes of immunocompromise [1–4]. It is characterized by the presence of gas formation within and around the pancreas parenchyma at the time of the diagnosis but also in the peripancreatic spaces. Abdominal (CT) is considered as the best imaging modality to detect abnormal air bubbles with both high sensibility and sensitivity. Pancreatic parenchymal necrosis is variable and better seen on enhanced CT images appearing as hypodense areas [3,5]. The two main causes of pancreatic gas are infection by Gram-negative organisms and enteropancreatic fistula. In our case, the two mechanisms could be associated because of the presence of air into the

main pancreatic duct [2,5]. Moreover, the presence of E. aerogenes in blood cultures suggested primary infection as an aetiological factor. The short time between the beginning of the symptoms and the development of gas in the pancreatic parenchyma in our case was unusual. Indeed, infections develop mostly during the first 2 or 3 weeks of the course of acute pancreatitis. Polymicrobial infection is frequent, the most common organisms being Escherichia coli, Klebsiella, Pseudomonas and Enterobacter [2,4]. Image-guided fine needle aspiration is necessary for microbiological analysis. Gas-forming infections have been also described in several others organs such as cholecystitis, gastritis, pyelonephritis, cystitis or Fournier gangrene [3]. Disclosure of interest: the authors declare that they have no conflicts of interest concerning this article.

References

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Daly JJ, Alderman DF, Conway WF. General case of the day. Emphysematous pancreatitis. Radiographics 1995;15:489–92. Wig JD, Kochhar R, Bharathy KG, Kudari AK, Doley RP, Yadav TD, et al. Emphysematous pancreatitis. Radiological curiosity or a cause for concern? JOP 2008;9:160–6.

tome 44 > n85 > mai 2015

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Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics 2002;22:543–61. Ku YM, Kim HK, Cho YS, Chae HS. Medical management of emphysematous pancreatitis. J Gastroenterol Hepatol 2007;22:455–6.

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Novellas S, Karimdjee BS, Gelsi E, Baudin G, Chevallier P. CT imaging features and significance of gas in the pancreatic bed. J Radiol 2009;90:191–8.

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Emphysematous pancreatitis. A rare cause of fulminant multiorgan failure.

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