PMC5348455_01
A picture of the right femoral region on admission. After a tentative incision was made, redness and swelling were observed in the right femoral region.
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The patient was an 80-year-old man who presented at the Department of Orthopedics in our hospital because of a fever of several days in duration and pain, swelling, and redness of the right thigh (Fig. 1).
Magnetic resonance images. A: A T1-weighted image, showing moderate-to-high signal intensity around the muscle. B: A fat-suppressed T2-weighted image, showing high signal intensity in the quadriceps femoris muscle, the gracilis muscle, and the semimembranosus muscle.
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Magnetic resonance imaging (MRI) was performed to determine the cause of inflammation of the right thigh (Fig. 2).
Abdominal contrast-enhanced computed tomographic scans. A, B: Atrophy and degeneration associated with a lack of parenchyma were observed in part of the uncinate process and the body of the pancreas. A good contrast effect was obtained in the pancreas. Cystic lesions were present in the uncinate process of the pancreas (arrowheads). C, D: Fluid retention extended from the duodenum to the right anterior pararenal space, the perirenal space, and the posterior pararenal space (circle). E: Fluid retention (circle) extended to the thigh over the ilium at the level of the femoral artery and vein (arrowheads).
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Abdominal computed tomography (Fig. 3) and magnetic resonance cholangiopancreatography (Fig. 4) were thus performed and showed cystic lesions in the pancreatic head.
Magnetic resonance cholangiopancreatography. Cystic lesions were present in the uncinate process of the pancreas (arrowheads). This image was not clear because of an artifact and the presence of a large amount of ascites.
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Pancreatography revealed cystic dilatation of the pancreatic ducts at the pancreatic head (Fig. 4A, arrow).
The endoscopic retrograde pancreatographic findings. A: Pancreatography showed the cystic dilation of a branch of the pancreatic duct at the head of the pancreas (arrow). The entire main pancreatic duct was dilated. Mild stricture was found in the main pancreatic duct at the head of the pancreas. B: Although we could not find an obvious leak from the pancreatic ducts, the contrast medium washed out quickly. C: Endoscopic pancreatic sphincterotomy was performed and a 7-French, 12-cm pancreatic stent was placed in the main pancreatic duct.
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On Day 14, endoscopic retrograde cholangiopancreatography was performed in order to place a pancreatic stent (Fig. 5).
The pathological findings. A: An elastic soft mass (6x8x5 cm, circle) extended from the pancreatic head and surrounded Gerota's fascia of the right kidney. B: The cut surface of the pancreatic head showed the presence of cystic lesions of various sizes, with the leakage of milky-white viscous fluid (arrowhead). The rupture point of the IPMN could not be located due to the presence of inflammation, necrosis, and fibrosis. A pancreatic stent had been placed in the main pancreatic duct. C: An enlarged view of the square area of B. D (x20): The histological findings of pancreatic head showed the presence of cystic lesions of various sizes. E: Macroscopic findings showed that the structures of the tail (circle) of the pancreas were relatively well preserved. F (x200): The histological findings showed that the acinar structures of the tail of the pancreas were relatively well preserved; small regions of fat necrosis were sporadically found and hyalinization of the islets of Langerhans had occurred due to diabetes mellitus. No fibrosis was found in the tail of the pancreas. The macroscopic and histological findings showed that there was no obvious chronic pancreatitis. G (x200): Atypical papillary proliferation was found in some of the cystic lesions at the pancreatic head, indicating the presence of an intraductal papillary mucinous adenoma (IPMA) of the pancreas.
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The cut surface of the mass showed cystic lesions of various sizes at the pancreatic head and discharged milky-white viscous fluid (Fig. 6A-D). The structures of the body and tail of the pancreas were relatively well preserved (Fig. 6E and F). Histologically, atypical papillary proliferation was observed in some of the cystic lesions at the pancreatic head, indicating the presence of an intraductal papillary mucinous adenoma (IPMA) of the pancreas (Fig. 6G).