Case Report

A 41-year-old Thai female with past medical history of gastroesophagealreflux disease and duodenal ulcer who immigrated to the United States six years ago presented with a complaint of intermittent right upper quadrant (RUQ) pain for the last several years. Over the last year, she reported that the pain had significantly increased in intensity. She described the pain as crampy, beginning in the RUQ and radiating around to her back. There was no associated nausea, vomiting or weight loss. The patient had initially presented to an outside hospital a few months prior, was diagnosed with costochondritis, and was subsequently discharged. Her family promptly drove her to theemergency room of the outside hospital with severe abdominalpain and fevers. A computed tomography (CT) scan done in the emergency room showed a 4.6 cm x 2.8 cm x 4.9 cm multi-loculated mass adjacent to the head of the pancreas along with several enlarged lymph nodes in close proximity to the mass. The patient was referred to an oncologist at a specialty cancer center where an endoscopic ultrasound (EUS) was performed. The EUS revealed a 5.1 cm x 2.2 cm hypoechoic, heterogeneous, septated lesion. Fine needle aspiration (FNA) was performed on the mass and cytology was sent to determine the etiology of the peripancreaticmass. The EUS-FNA cytology demonstrated necrotizing granulomatous inflammation, but specials stains for tuberculosis and fungal etiologies were negative.