Case Report
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World J Gastroenterol. Dec 21, 2013; 19(47): 9127-9132
Published online Dec 21, 2013. doi: 10.3748/wjg.v19.i47.9127
Localized type 1 autoimmune pancreatitis superimposed upon preexisting intraductal papillary mucinous neoplasms
Takahiro Urata, Yoshiki Naito, Yoshihiro Izumi, Yoshi Takekuma, Hiroshi Yokomizo, Michiko Nagamine, Seiji Fukuda, Kenji Notohara, Michio Hifumi
Takahiro Urata, Yoshihiro Izumi, Yoshi Takekuma, Michio Hifumi, Department of Gastroenterology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan
Yoshiki Naito, Department of Pathology, Kurume University School of Medicine, Kurume City, Fukuoka 830-0011, Japan
Hiroshi Yokomizo, Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan
Michiko Nagamine, Seiji Fukuda, Department of Pathology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan
Kenji Notohara, Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki City, Okayama 701-01, Japan
Author contributions: Urata T and Naito Y designed the report; Urata T, Izumi Y, Takekuma Y and Hifumi M were attending doctors for the patients; Yokomizo H performed surgical operation, Naito Y, Nagamine M, Fukuda S and Notohara K performed pathological examinations; Urata T wrote paper.
Correspondence to: Takahiro Urata, MD, Department of Gastroenterology, Japanese Red Cross Kumamoto Hospital, 2-1-1, Nagamine Minami, Kumamoto city, Kumamoto 861-8520, Japan.
Telephone: +81-96-3842110 Fax: +81-96-3843939
Received: May 22, 2012
Revised: September 27, 2013
Accepted: November 2, 2013
Published online: December 21, 2013

A 70-year-old woman was found to have 2 cystic lesions in the head of the pancreas on abdominal ultrasonography during a routine medical examination. Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography showed multilocular cysts in the head of the pancreas without dilation of the main pancreatic duct. The patient was followed-up semiannually with imaging studies for suspected branch duct-type intraductal papillary mucinous neoplasm (IPMN). At 3 years after initial presentation, hypoechoic lesions were observed around each pancreatic cyst by EUS. Diffusion-weighted imaging showed high-intensity regions corresponding to these lesions. Therefore, a diagnosis of invasive carcinoma derived from IPMN could not be excluded, and subtotal stomach-preserving pancreaticoduodenectomy was performed. The macroscopic examination of the surgical specimen showed whitish solid masses in the head of the pancreas, with multilocular cysts within each mass. Microscopically, each solid mass consisted of inflammatory cells such as lymphocytes and plasma cells. Furthermore, immunochemical staining revealed immunoglobulin G4-positive cells, and many obliterating phlebitides were observed. The cysts consisted of mucus-producing epithelial cells and showed a papillary growth pattern. Based on these findings, we diagnosed multiple localized type 1 autoimmune pancreatitis occurring only in the vicinity of the branch duct-type IPMN.

Keywords: Autoimmune pancreatitis, Intraductal papillary mucinous neoplasm, Immunoglobulin G4, Endoscopic ultrasonography, Diffusion-weighted imaging

Core tip: We herein report a case of localized type 1 autoimmune pancreatitis (AIP) superimposed upon preexisting multifocal intraductal papillary mucinous neoplasms (IPMNs) of the branch duct. Although few reports have shown AIP associated with IPMN, in our case, AIP had developed only around the IPMN, which was under progressive observation. Therefore, the IPMN may have influenced the pathogenesis of AIP.