Abstract | March 24, 2024

Pancreatic Mass: Cancer or Blastomycosis?

Tina Phan, MD, PGY-4, University of Tennessee Health Science Center, Memphis, TN

Gabrielle Howard, MD, Rheumatology, The Bone and Joint Center, Springfield, MO; Nayna Riyat, MD, Gastroenterology, Stanford, Stanford, CA; Thomas Wells, MD, Gastroenterology, Graves Gilbert Clinic, Bowling Green, KY, Christopher Jackson, MD, Associate Professor, Internal Medicine, University of Tennessee Health Science Center, Memphis, TN; Neena Thomas-Gosain, MD, Infectious Disease, University of Wisconsin Medical School, Madison, WI, Vickie Baselski, MD, Professor, Pathology, University of Tennessee Health Science Center, Memphis, TN; Ilya Stone, MD, Pathology, University of Tennessee Health Science Center, Memphis, TN; Bradford Waters, MD, Gastroenterology, University of Tennessee Health Science Center, Memphis, TN; Claudio Tombazzi, MD, Associate Professor, Gastroenterology, University of Tennessee Health Science Center, Memphis, TN

Learning Objectives

  1. Blastomyces dermatitidis, a fungal mycosis endemic to the Mississippi and Ohio River valleys, that presents with nonspecific symptoms, including cough, fever, nights sweats, and weight loss
  2. Disseminated blastomycosis should be considered in immunocompetent patients from endemic areas with a rapidly growing pancreatic mass, even though pancreatic involvement is atypical

Introduction: Disseminated blastomycosis is known to have pulmonary and cutaneous manifestations, but gastrointestinal involvement is rare. We present a case of pancreatic blastomycosis in an immunocompetent patient.

Case: A 67-year-old male with a history of hepatitis C and type 2 diabetes mellitus presented with anorexia, a twenty-five pound weight loss, right shoulder and flank pain, weakness, and dyspnea over the last three months.
On physical examination, he had multiple cutaneous masses over his right post-auricular region, right shoulder, and right flank, with the largest one measuring four centimeters. A computed tomography scan of the chest, abdomen, and pelvis showed a cystic lesion in the pancreatic head, a right lower lobe mass with adjacent airspace disease, and a soft tissue mass in the right flank.

We were most concerned for sepsis secondary to a post-obstructive pneumonia and metastatic pancreatic cancer, but we also considered infiltrative and infectious processes. Despite empiric antibiotics, the patient’s condition worsened with new fevers and persistent tachycardia. Repeat imaging one week later showed a growing pancreatic lesion. The pancreatic mass was then biopsied, but pathology was negative for malignancy and fungal components on special stains. Pathology from a bronchoalveolar lavage demonstrated broad-based budding yeast. The patient was diagnosed with disseminated blastomycosis, supported by a positive urine blastomycosis antigen test.

Diagnosis: Blastomyces dermatitidis, a fungal mycosis endemic to the Mississippi and Ohio River valleys, is rarely identified in the gastrointestinal tract. To our knowledge, there are fewer than five documented cases with pancreatic involvement. In recognized cases of pancreatic blastomycosis, all patients were immunocompetent, emphasizing the observed fact that blastomycosis does not only cause metastatic disease in immunocompromised patients. Our case was unique since the pancreatic biopsy was negative for budding yeast. However, pancreatic blastomycosis remained the likely diagnosis given the mass resolution with treatment and a negative biopsy for malignancy. This case highlights that disseminated blastomycosis should be considered in immunocompetent patients from endemic areas with a rapidly growing pancreatic mass, even though pancreatic involvement is atypical.

Outcome: The patient was started on amphotericin B with symptom improvement. Repeat imaging demonstrated complete resolution of the pancreatic mass.

References and Resources

  1. Saccente M. Woods G. Clinical and laboratory update on blastomycosis. Clinical Microbiology Reviews 2010; 23(2): 367-381.
  2. Perez-Lasala, G. Nolan R. Chapman S. Achord J. Peritoneal Blastomycosis. The American Journal of Gastroenterology 1991; 86: 357-359.
  3. Blastomycosis cooperative study of the veteran’s administration: Blastomycosis: 1. A review of 198 collected cases in veteran’s administration hospitals. Am Rev Respir Dis 1964; 89(5): 659-672.
  4. Deutsch JC. Burke TL. Nelson TC. Pancreatic and splenic blastomycosis in an immune-competent woman diagnosed by endoscopic ultra-sonography-guided fine-needle aspiration. Endoscopy 2007; 39: 272-273.
  5. Mouser H. Miller FH. Berggruen SM. Case 233: Blastomycosis. Radiology 2016; 280: 972-977.
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