Acute suppuration of the pancreatic duct in a patient with tropical pancreatitis

Pancreatic sepsis secondary to infected necrosis, pseudocyst, or pancreatic abscess is a well-known clinical entity. Acute suppuration of the pancreatic duct (ASPD) in the setting of chronic calcific pancreatitis and pancreatic ductal obstruction with septicemia is a rare complication that is seldom reported. It is our aim to report a case of ASPD with Klebsiella ornithinolytica, in the absence of pancreatic abscess or infected necrosis.

A 46-year-old Asian-Indian man with chronic tropical pancreatitis who was admitted with recurrent epigastric pain that rapidly evolved into septic shock. A CT scan of abdomen revealed a dilated pancreatic duct with a large calculus. Broad-spectrum antibiotics, vasopressors and activated recombinant protein C were initiated. Emergency ERCP showed the papilla of Vater spontaneously expelling pus. Probing and stenting was instantly performed until pus drainage ceased. Repeat CT scan confirmed the absence of pancreatic necrosis or fluid collection, and decreasing ductal dilatation. Dramatic clinical improvement was observed within 36 hours after intervention. Blood cultures grew Klebsiella ornithinolytica. The patient completed his antibiotic course and was discharged.

ASPD without pancreatic abscess or infected necrosis is an exceptional clinical entity that should be included in the differential diagnosis of pancreatic sepsis. A chronically diseased pancreas and diabetes may have predisposed to the uncommon pathogen. The presence of intraductal pancreatic stones obstructing outflow played a major role in promoting bacterial growth, suppuration and septicemia. Immediate drainage of the pancreatic duct with endoscopic intervention is critical and mandatory.