Table of Contents  
COMMENTARY
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 516-517  

Infection of the pancreas: Myriad of hues


Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication12-Jul-2016

Correspondence Address:
Vishal Sharma
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh - 110 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.186076

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How to cite this article:
Sharma V. Infection of the pancreas: Myriad of hues. Med J DY Patil Univ 2016;9:516-7

How to cite this URL:
Sharma V. Infection of the pancreas: Myriad of hues. Med J DY Patil Univ [serial online] 2016 [cited 2022 Oct 5];9:516-7. Available from: https://www.mjdrdypu.org/text.asp?2016/9/4/516/186076



Pancreas is an important retroperitoneal organ that has vital exocrine and endocrine functions playing an important role in digestion and assimilation of ingested food and in maintaining glucose homeostasis in the body. Pancreatic afflictions may be due to inflammatory, traumatic, toxic, neoplastic, infiltrative, and occasionally infective processes. As acute pancreatitis (related usually to alcohol or gallstones), chronic pancreatitis (alcoholic, genetic or idiopathic), and pancreatic neoplasms are the commonly encountered disorders, other diseases such as infective involvement are often not paid much attention to by clinicians and pancreatologists. Pancreatic infections can present in a number of fashions including acute pancreatitis (as in the present case) or like chronic pancreatitis or may even mimic pancreatic neoplasms. A number of infective pathogens have been implicated in the genesis of acute pancreatitis [Table 1] and in tropical countries such as India, one should always be wary of infections such as malaria, hepatitis E virus (HEV), dengue, ascariasis, tuberculosis, and human immunodeficiency virus (HIV) related conditions as cause of pancreatic diseases.[1],[2],[3],[4],[5],[6],[7] Since it is virtually impossible to summarize all the infective processes that may involve the pancreas in this commentary, only the infections of importance to India are briefly discussed.
Table 1: Infections of the pancreas

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As in the present report, malarial parasite has been reported to cause pancreatitis, and the disease is often clinically manifest and significant. In fact, malarial pancreatitis is often severe and associated with significant morbidity and mortality. Although traditionally the reports implicated Plasmodium falciparum, recent reports indicate that Plasmodium vivax may also cause severe acute pancreatitis.[1] Virtually, all hepatitis viruses have been implicated in causing acute pancreatitis in some of the cases. However, HEV-related pancreatitis has been implicated as a cause of around 2% of all cases of acute pancreatitis at a large tertiary care center in North India. HEV-related pancreatitis seems to dominantly affect males, and has a good outcome, and most cases are of mild interstitial pancreatitis.[2] Dengue, another hepatitis virus, which is known to cause thrombocytopenia, plasma leak, and liver dysfunction is also implicated in the causation of acute pancreatitis, occasionaly.[3] Also of interest is the causation of acute pancreatitis by worms especially the roundworm, Ascaris lumbricoides. The worm may block the pancreatic duct or bile duct and may, therefore, result in obstructive acute pancreatitis. Diagnosis should be considered in patients residing in endemic areas (like Kashmir) when no other etiology is apparent. Side viewing endoscopy may demonstrate live Ascaris at the ampulla of Vater. The worms may also be demonstrated on abdominal ultrasound and endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography to remove the worms from the ampulla and administration of antihelminthic drugs are used for treatment in such cases.[4] In most of these clinical situations, the therapy usually includes antiinfective agents to tackle the infection although whether this really affects the course of pancreatitis is uncertain. In situ ation like HEV-related AP, no specific therapy is usually administered, and the treatment includes management of fluid and electrolytes, treatment of organ dysfunction and any local complications.

Unlike the above-described pathogens, tuberculosis causes more chronic presentation and often mimics pancreatic malignancy. Indeed, the diagnosis is often made on histological examination of resected specimen of a presumed pancreatic cancer. Tuberculosis of the pancreas can present in myriad of fashions including obstructive jaundice, head mass, pancreatic cyst, or mass and even calcifications. The availability of endoscopic ultrasound has helped in early diagnosis and avoidance of surgery in many cases.[5] As mentioned, pancreatic tuberculosis closely mimics pancreatic cancer and may also have associated vascular invasion which adds to the diagnostic confusion.[6] Pancreatic tuberculosis seems to respond well to anti-tubercular therapy and in many cases, obstruction jaundice may resolve even without the need for biliary decompression.[5]

Another area of concern is the occurrence of pancreatitis in patients infected with HIV. While often the cause is related to the drugs administered as part of highly active antiretroviral therapy, it may also be related to opportunistic infections as the risk of pancreatitis is related to lower CD4 counts.[7] Possible infectious agents which may cause pancreatitis in HIV patients include (but are not limited to) cytomegalovirus, tuberculosis, Mycobacterium avium viruses such as Herpes viruses, fungi such as Cryptococcus and Candida, Pneumocystis jiroveci, and protozoa such as the Toxoplasma gondii and Leishmania donovani.[8]

To summarize, infective agents can involve the pancreas in a variety of manners. The presentation may be in acute pancreatitis like pattern or may be more indolent. The clinicians managing patients who are immunosuppressed or residents of tropical regions should stay alert to the possibility of infection as a cause of pancreatitis when more common etiologic factors such as alcohol and gallstones have been excluded.

 
  References Top

1.
Sharma V, Sharma A, Aggarwal A, Bhardwaj G, Aggarwal S. Acute pancreatitis in a patient with vivax malaria. JOP 2012;13:215-6.  Back to cited text no. 1
    
2.
Raj M, Kumar K, Ghoshal UC, Saraswat VA, Aggarwal R, Mohindra S. Acute hepatitis E-associated acute pancreatitis: A single center experience and literature review. Pancreas 2015;44:1320-2.  Back to cited text no. 2
    
3.
Jain V, Gupta O, Rao T, Rao S. Acute pancreatitis complicating severe dengue. J Glob Infect Dis 2014;6:76-8.  Back to cited text no. 3
    
4.
Phisalprapa P, Prachayakul V. Ascariasis as an unexpected cause of acute pancreatitis with cholangitis: A rare case report from urban area. JOP 2013;14:88-91.  Back to cited text no. 4
    
5.
Sharma V, Rana SS, Kumar A, Bhasin DK. Pancreatic Tuberculosis. J Gastroenterol Hepatol 2015 doi: 10.1111/jgh.13174.  Back to cited text no. 5
    
6.
Rana SS, Sharma V, Sampath S, Sharma R, Mittal BR, Bhasin DK. Vascular invasion does not discriminate between pancreatic tuberculosis and pancreatic malignancy: A case series. Ann Gastroenterol 2014;27:395-8.  Back to cited text no. 6
    
7.
Dragovic G. Acute pancreatitis in HIV/AIDS patients: An issue of concern. Asian Pac J Trop Biomed 2013;3:422-5.  Back to cited text no. 7
    
8.
Al Anazi AR. Gastrointestinal opportunistic infections in human immunodeficiency virus disease. Saudi J Gastroenterol 2009;15:95-9.  Back to cited text no. 8
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