Images in Clinical Medicine

Tropical Calcific Pancreatitis

Frederick J. Lee, M.B., B.S., and James Raleigh, M.B., B.S.

N Engl J Med 2011; 365:1425October 13, 2011

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A 40-year-old Fijian man with human immunodeficiency virus (HIV) infection (CD4 cell count, 190 per cubic millimeter) presented with a 72-hour history of severe epigastric pain, nausea, and vomiting. Similar episodes of epigastric pain had occurred several times, preceding the diagnosis of HIV infection by 20 years. Laboratory investigations revealed an elevated serum lipase level (173 U per liter), suggesting a diagnosis of pancreatitis. He did not drink alcohol, and investigations performed during previous episodes had not identified other causes of pancreatitis. Plain radiographs (Panel A) and computed tomographic images (Panel B, coronal view) of the abdomen revealed coarse, well-defined, and dense calcifications within the body of the pancreas (arrows). The pattern is typical of the large intraductal calculi of tropical calcific pancreatitis, which has been increasingly recognized as a cause of early-onset, nonalcoholic, chronic pancreatic disease in tropical and near-tropical developing nations. The cause of this condition remains obscure, although susceptibility mutations in the gene encoding serine protease inhibitor Kazal type 1 (SPINK1) have been identified. Tropical calcific pancreatitis is associated with neither HIV infection nor antiretroviral therapy and often leads to insulin-dependent, but ketosis-resistant, diabetes mellitus. The patient's epigastric pain resolved with conservative therapy within 7 days.

Frederick J. Lee, M.B., B.S.
St. Vincent's Hospital, Sydney, NSW, Australia
flee3@stvincents.com.au

James Raleigh, M.B., B.S.
Royal Prince Alfred Hospital, Sydney, NSW, Australia

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