2017/10/01 by Sonal Gandhi, Niraj Jani
Medicine · #Cholangiocarcinoma and Gallbladder Cancer Studies #Viral-associated cancers and disorders #HIV/AIDS drug development and treatment
paper · doi:10.14309/00000434-201710001-01378
CASE REPORT: The patient is a 40-year-old male with history of HIV on Stribild and HTN presented with 1 month history of severe abdominal pain and 25lb weight loss. He had elevated LFT's and abdominal USG showed gall bladder sludge, no wall thickening or bile duct dilatation. HIDA scan showed chronic cholecystitis. ERCP showed pancreatic duct and distal CBD strictures requiring stent placement. Cytology brushings were obtained and initial pathology was negative for malignancy. Patient underwent laparoscopic cholecystectomy and was discharged home. He was re-admitted 2 weeks later with worsening abdominal pain concerning for acute pancreatitis likely secondary to HAART. FISH analysis was concerning for high grade dysplasia or malignancy of the pancreatobiliary tract. CA 19-9 was normal. Pancreatitis was treated conservatively and patient underwent ERCP/EUS which revealed severe CBD stricture requiring stent placement. FNAC performed in the body of the pancreas was concerning for cholangiocarcinoma (CC). 2 weeks later, he underwent exploratory laparotomy and Whipple procedure. PET/CT was concerning for a metastatic disease with plan to start chemotherapy with gemcitabine/cisplatin. He continues to have severe abdominal pain likely from chronic pancreatitis. DISCUSSION: In general, HIV is associated with increased risk of malignancies. Non-Hodgkin's lymphoma and Kaposi sarcoma are AIDS defining diseases and Hodgkin's Lymphoma, myeloid leukemia are linked to HIV. Biliary neoplasms are not commonly associated with HIV. CC is a rare adenocarcinoma of bile duct epithelium seen commonly in males. Clinical presentation and lab studies can be non specific. CT or MRI abdomen can reveal a mass but ERCP/ EUS are preferred imaging and diagnostic modalities. Treatment options include surgery followed by chemo-radiation. HIV/AIDS infected patients have high risk of neoplasm involving the liver. HIV related cholangitis/cholangiopathy are often associated with an infective etiology like CMV, cryptosporidium etc. It has been postulated in many studies that cholangitis in HIV patients can cause CC due to chronic inflammation/chronic cholestasis, either diectly from HIV or from opportunistic infections. There is data postulating ART or immuno suppresion causing CC. There is still no clear understanding of relationship between HIV infection, cholangitis and cholangiocarcinoma, necessitating the need for increasing body of supporting literature and case reports.Figure: EUS image showing invasion into pancreatic head.Figure: Cholangiogram showing bile duct stenosis.Figure: EUS image showing diffusely thickened bile duct wall.