When you hear hoofbeats… Nancy Fuller, M.D. Nov 28, 2007

Objectives: Think of Zebras but… Expect Horses No financial disclosures

57 yo woman with 2-3 weeks of worsening epigastric and right sided pain 2 months prior, she had some epigastric discomfort and nausea-Fosamax? Self treated with discontinuation and omeprazole. Called now because worsening pain, mother to have a mastectomy soon.

PMHx: large vessel vasculitis in 2002, presenting with claudication symptoms in the arms; treated with prednisone and now quiescent Osteopenia Vein stripping

Meds: DHEA 2 times per week Prednisone 2.5 mg per day MVI Calcium, magnesium Omega-3 fatty acids Coenzyme Q10 -Works as a nurse at UW

Too busy to come to clinic; phone conversation-gallstones? GERD? Ultrasound: 6 cm X 7 cm heterogeneous mass in the liver Of note, patient had a series of CT scans of the liver since 2003 following a probably vascular lesion; that was stable.

New ideas? -cancer? She was up to date on mammogram and had a colonoscopy 1 year ago -Infection??? She had traveled to Mexico in Feb 2007…

Entamoeba histolytica amebiasis Amebic liver abscess is the most common extraintestinal manifestation Amebae ascend the portal venous system Endemic in Mexico; not common in short term visitors but can occur after travel exposures as short as 4 days

Haque R et al. N Engl J Med 2003;348: Life Cycle of Entamoeba histolytica

E. histolytica More common in men than women, although equal gender distribution in children Usually presents with right upper quadrant pain and fever, almost always within 5 months of exposure Often have leukocytosis and elevated alk phos, hepatic enzymes

E. histolytica Diagnosis: imaging reveals a single abscess in the liver 70-80% of the time Abscess is ‘cold’; does not always look like a classic abscess and may be confused with malignancy Serum antibodies positive in nearly all patients Needle aspiration not recommended

The patient recalled being ill in Mexico after arrival but had recovered uneventfully Next day: CBC, LFTs, E. histolytica antibody test, CT scan.

Labs: WBC 9.6, H/H 13.4/39, plts 305, INR 1.0, t. bili 0.5, alk phos 332, GGT 567, AST 52, Cr 0.8 CT abdomen: “interval development of large pancreatic mass… and innumerable low- attenuating lesions… consistent with metastatic disease”. Bx: adenocarcinoma of the pancreas CA19-9 greater than 35,000 E. histolytica antibody-negative

Dx: metastatic pancreatic cancer 4th leading cause of cancer deaths in the US Surgical resection is the only potentially curative treatment, but only 15-20% present with potentially resectable disease Prognosis is poor even with resectable dx

Risk factors: chronic pancreatitis, smoking, DM, and hereditary predisposition to pancreatic cancer, or multiple cancers Most common presenting features: abdominal pain, weight loss, jaundice Dx usually CT, but can include ERCP, MRI, etc. C19-9 is closely related to tumor size and not considered helpful in screening (often mildly elevated in benign disease)

My patient: enrolled in a trial with gemcitabine (similar to cytarabine) and capecitabine (converts to 5 FU) Main toxicity: skin rash, fatigue, oral ulcers She is currently doing well, very optimistic and happy because her CA19-9 has decreased by nearly half She plans to travel back to Mexico if well enough in the spring.