case_images: PMC3897989_01
case_images: CT and MRI scan of the patient. Uncontract CT image (A), T1 weighted image (D) and T2 weighted image (E) displayed diffusive enlargement of the pancreas capsuled by an armorlike rim, significant dilation of intra- and extra-heptic bile duct and gallbladder, and atrophy of the right kidney. Contrast CT (B: arterial phase; C: venous phase) and MRI (F) revealed homogeneously enhanced pancreas and diffusive thickening of the gallbladder wall. Repeat MRI (G) after effective treatment showed remarkable reduction of the pancreas, gallbadder and bile ducts. Chest CT (H) showed a large patchy shadow in the right lower lobe. Repeat CT (I) after antibiotic treatment showed remarkable absorption of the lesion.
case_images: 1471-230X-14-10-1.jpg
case_images: PMC3897989_01_1471-230X-14-10-1.jpg
case_images: F1
case_images: Both computed tomography (CT) and magnetic resonance image (MRI) revealed diffusive enlargement of the pancreas, capsuled by an armorlike low-density rim and enhanced homogenously (Figure 1). The patient was diagnosed with pulmonary abscess and was treated effectively with moxifloxacin (Figure 1).
case_images: Clinical course of liver enzymes and bilirubin during combination therapy with ursodeoxycholic acid (UDCA) and methylprednisolone (MEP).
case_images: 1471-230X-14-10-2.jpg
case_images: PMC3897989_01_1471-230X-14-10-2.jpg
case_images: F2
case_images: Based on the biochemical evidence of cholestasis from the elevation of ALP, gamma-GT and TBil, and the presence of AMA, the patient was clinically diagnosed with PBC and UDCA (250 mg, three times per day) was initiated immediately after nasobiliary drainage, which partially improved the patient's liver function (Figure 2). The patient was discharged and followed up at the clinic with MEP tapered off weekly by 5 mg. The clinical course is depicted in Figure 2.
case_images: Hematoxylin and eosin (HE) staining and immunohistochemistry (IHC) of the pancreatic tissue. HE stain (A, x200) showed dense lymphoplasmacytic infiltration and fibrosis. IHC (B) showed abundant IgG4+ plasma cell infiltration.
case_images: 1471-230X-14-10-3.jpg
case_images: PMC3897989_01_1471-230X-14-10-3.jpg
case_images: F3
case_images: IgG4+ plasma cell was stained and counted to be as high as 95 per high-power field (HPF) (Figure 3).