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Mycophenolate-mofetil/prednisone/tacrolimus Pancreaticoduodenal malakoplakia secondary to infections: case report

A 66-year-old man developed pancreaticoduodenal malakoplakia secondary to Escherichia coli, Streptococcus salivarius group, Staphylococcus epidermidis and Candida guilliermondii complex infections following immunosuppressive therapy with mycophenolate mofetil, prednisone and tacrolimus [routes, dosages and durations of treatments to reaction onset not stated; not all outcomes stated] . The man presented with right upper quadrant pain, weight loss, fatigue and decreased appetite. Fourteen months earlier, he had undergone orthotopic heart transplantation for non-ischaemic cardiomyopathy. He had been receiving immunosuppressive therapy with mycophenolate mofetil, prednisone and tacrolimus. On physical examination, he had a positive murphy sign. Laboratory investigation showed an increased serum alkaline phosphatase. A contrast-enhanced magnetic resonance (MR) showed a 10.3-cm mass in the head of the pancreas and duodenum, associated with dilation of the gallbladder, main pancreatic duct and bile ducts.The lobulated mass was T1 and T2 isointense to uninvolved pancreatic parenchyma. The lesion also showed heterogeneous enhancement to a greater degree than adjacent normal pancreas and marked diffusion restriction. An endoscopic ultrasound revealed heterogeneously hypoechoic mass with associated common bile duct (CBD) dilation. Core needle biopsy of the mass showed pancreatic tissue comprising benign pancreatic elements, abundant foamy macrophages with histiocytic reaction and cytoplasmic laminated concretions with positive calcium staining (Michaelis-Gutmann bodies). All these findings were consistent with malakoplakia. A tissue culture grew Escherichia coli, Streptococcus salivarius group and coagulase-negative Staphylococcus species. Subsequently, the man was treated with ceftriaxone and metronidazole. The coagulase-negative Staphylococcus species was felt to be a contaminant. After 4 weeks, he was readmitted to the hospital due to persistent right upper quadrant pain with jaundice. Laboratory investigations were significant for an elevated total bilirubin, alkaline phosphatase, AST and ALT. An endoscopic retrograde cholangiopancreatography (ERCP) demonstrated moderate extrinsic compression of the duodenal bulb, which had not been present on the initial endoscopic ultrasound. A large periampullary ulcerated mass and a severe stricture of the distal CBD were observed, which were biopsied, brushed and stented. Non-enhanced (NE) CT scan revealed the mass had grown to 11.2cm with diffuse high attenuation and central coarse calcifications. A repeat biopsy of the mass re-demonstrated malakoplakia. Cultures grew Staphylococcus epidermidis and Candida guilliermondii complex. The mass increased in size despite several weeks of targeted unspecified antibiotic therapy. Thus, he received doxycycline and fluconazole. Additionally, he was also treated with bethanechol and ascorbic acid to reestablish the normal bal