Pancreatic sarcoidosis discovered during Whipple procedure
The patient is an asymptomatic 60-year-old African American female, who was referred to our institution for an elevated CA19-9. Her past medical history included diabetes mellitus, asthma, hypertension, hypercholesterolemia, obstructive sleep apnea and osteoarthritis. She denied abdominal pain, decreased appetite, nausea, vomiting, diarrhea, pruritus, jaundice, acholic stool or dark urine. She had no fevers, night sweats or other constitutional symptoms. She denied alcohol or tobacco use. Her family history was significant for colon and breast carcinoma. Her vital signs were within normal limits. She had no lymphadenopathy on examination of the head and neck. Abdominal exam revealed an obese, soft, non-tender, non-distended abdomen with no hepatosplenomegaly. The cardiovascular, neurologic and pulmonary exams were unremarkable. Computer tomography (CT) scan of her abdomen revealed a smooth shaped lesion involving the pancreatic head, measuring 3.6 cm at its greatest diameter (Fig. ). Mesenteric lymphadenopathy was also noted, with the largest node measuring 2.3 cm in diameter. The liver, spleen, gallbladder and cystic duct were normal. These CT findings were consistent with pancreatic neoplasm and prompted surgical referral. After consultation, the patient agreed to a Whipple procedure. An endoscopic ultrasound (EUS) or fine needle aspiration biopsy was not preformed preoperatively.\nAn upper midline laparotomy for a classic Whipple procedure was performed. After mobilization of the transverse colon, the pancreas and duodenum were visualized. On the mesentery near the pancreas there were several subcentimeter nodes which were excised and sent for frozen section. On the posterior surface of the pancreatic head, a large peripancreatic lymph node was identified and excised (Fig. ). Intraoperative frozen section showed non-caseating granuloma, at which time the decision was made to abort the procedure. Postoperatively the patient had a smooth recovery. Drains were removed on post-op day 3 with minimal output. She spent an additional 2 days on the ward, after which she was discharged.\nOn gross pathological examination the specimen contained one peripancreatic lymph node, measuring 2.5 × 2.5 × 2 cm. Microscopic examination revealed normal lymph nodal effacement by granulomas composed of epithelioid cells with scattered Langhans giant cells and lymphocytes. Ziehl–Neelsen stain for acid fast bacilli (AFB) was negative. Grocott's methenamine silver stain for fungus was negative.