case_images: PMC5903122_01
case_images: Axial contrast-enhanced CT images of the pancreas in the arterial phase of imaging demonstrate multifocal hypoenhancing lesions (arrows) throughout the pancreatic head and neck (a), pancreatic body (b), and pancreatic tail (c). There is superimposed mild peripancreatic fat stranding (arrowheads) in keeping with inflammation and/or fibrosis. Axial contrast enhanced T1-weighted MR images of the pancreas in the arterial phase of imaging demonstrate multifocal hypoenhancing lesions (arrows) throughout the pancreatic head and neck (d), pancreatic body (e), and pancreatic tail (f). Corresponding axial T2-weighted MR image (g) shows that the lesions demonstrate corresponding isointense to slightly hyperintense signal. These lesions demonstrate hyperintensity on diffusion weighted images (h) and hypointensity on the corresponding ADC map (i) reflecting restricted diffusion. Noncontrast heavily T2-weighted MRCP image of the pancreas in the coronal projection (j) demonstrates mild segmental stenoses of the main pancreatic duct (arrows) with minimal upstream dilatation.
case_images: crg-0012-0046-g01.jpg
case_images: PMC5903122_01_crg-0012-0046-g01.jpg
case_images: F1
case_images: CT imaging demonstrated slight diffuse enlargement of the pancreas with heterogeneous attenuation and the suggestion of multifocal heterogeneous hypoattenuating hypoenhancing masses with mild segmental pancreatic ductal narrowing and minimal ductal dilatation (Fig. 1a-c). Contrast-enhanced MR imaging on a 1.5-T scanner confirmed these findings (Fig. 1d-i) with areas of mild main pancreatic ductal narrowing also confirmed on magnetic resonance cholangiopancreatography (MRCP) (Fig. 1j).
case_images: Hematoxylin-eosin staining of fine needle aspiration specimens of the pancreatic mass-like lesions demonstrates a few neutrophils (arrows) in close approximation to the ductal epithelium suggestive of early granulocyte epithelial lesion formation.
case_images: crg-0012-0046-g02.jpg
case_images: PMC5903122_01_crg-0012-0046-g02.jpg
case_images: F2
case_images: Pathology from the fine needle aspiration demonstrated areas of fibrosis and periductal lymphoplasmocytic infiltrate as well as neutrophils in close approximation to the ductal epithelium (Fig. 2).
case_images: One month following initiation of steroid treatment, axial contrast enhanced CT images (a-c) of the pancreas in the arterial phase of imaging demonstrate resolution of the previously seen multifocal lesions and peripancreatic stranding with normal homogenous enhancement of the pancreas. A stent in the common bile duct (arrow) was placed during the patient's initial hospitalization for a short segment stricture.
case_images: crg-0012-0046-g03.jpg
case_images: PMC5903122_01_crg-0012-0046-g03.jpg
case_images: F3
case_images: Contrast-enhanced CT imaging at that time demonstrated interval resolution of the previously seen multifocal pancreatic masses and areas of extrinsic compression of the main pancreatic duct (Fig. 3).