Cervical extension of pancreatic pseudocyst: An unusual cause of neck stiffness and dysphagia

SA Journal of Radiology ISSN: (Online) 2078-6778, (Print) 1027-202X Page 1 of 4 Case Report Cervical extension of pancreatic pseudocyst: An unusual cause of neck stiffness and dysphagia Authors: Sneha Harish C1 Rashmi Dixit1 Sapna Singh1 Anjali Prakash1 Affiliations: 1 Department of Radiodiagnosis, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India Corresponding author: Sneha Harish, Dates: Received: 25 Dec. 2021 Accepted: 01 Mar. 2022 Published: 09 May 2022 How to cite this article: Harish C S, Dixit R, Singh S, Prakash A. Cervical extension of pancreatic pseudocyst: An unusual cause of neck stiffness and dysphagia. S Afr J Rad. 2022;26(1), a2385. https://doi.org/ 10.4102/sajr.v26i1.2385 Copyright: © 2022. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. Pancreatic pseudocyst is a common complication that can occur following acute or chronic pancreatitis. Commonly, they are peripancreatic in location. Rarely, they can extend to the mediastinum, and further extension to the neck is even rarer. A 55-year-old man who presented with neck stiffness and dysphagia and on imaging, was found to have a cystic lesion in the neck. Aspiration of the lesion revealed raised amylase levels suggestive of a pancreatic pseudocyst. Keywords: pancreatitis, pseudocyst, cervical extension, dysphagia, neck stiffness, mediastinal pseudocyst, computed tomography. Introduction Pancreatic pseudocyst is a very common complication that can occur following either acute or chronic pancreatitis. It is seen in about 30% – 40% of patients with chronic pancreatitis.1 Commonly, these cysts are found in peripancreatic locations. Rarely, they can extend into the mediastinum through anatomical defects in the diaphragm.2,3,4,5,6 Further extension to the neck is even rarer and has been described in a few case reports only.7,8,9 These can present with neck swelling or mass effect on the adjacent structures, and patients may present with complaints of dysphagia, chest pain or shortness of breath. Due to the varied clinical presentation, diagnosis is often challenging. Cross-sectional imaging such as CT is an excellent tool to establish the diagnosis. This report describes the case of a 55-year-old man with cervical extension of a pancreatic pseudocyst. Case report A 55-year-old male patient presented to the Emergency Department with complaints of neck stiffness and dysphagia for one week. There was no history of trauma or fever. Occasional alcohol intake was documented. At examination, the patient had limited neck movements along with tachypnoea. However, the lung auscultation findings were normal. The abdomen was soft and non-tender with no obvious palpable lump. A radiograph of the neck and cervical spine was obtained (Figure 1a and b), which indicated thickened prevertebral soft tissue causing anterior displacement of the airway. Degenerative changes were seen in the cervical spine. No evidence of discitis or vertebral osteomyelitis was seen. A chest radiograph acquired at the same time (Figure 1c) revealed a homogenous opacity causing displacement of the right paratracheal stripe and thickening of the paravertebral stripe. Another near-homogenous opacity was seen in the retrocardiac region, silhouetting the left hemidiaphragm. Given the radiographic findings and clinical scenario, the possibility of retropharyngeal abscess with mediastinal extension was considered. A contrast-enhanced CT scan of the neck and chest was conducted. It revealed a hypodense peripherally enhancing cystic lesion involving the prevertebral and retropharyngeal spaces of the neck, extending from the base of the skull to the level of the thoracic inlet (Figure 2a and b). Further caudally, it was seen to extend into the mediastinum, involving the visceral compartment, causing anterior displacement of the trachea and oesophagus (Figure 3a–c). More distally, the lesion was seen to extend through the oesophageal hiatus of the diaphragm into the abdomen, involving the lesser sac and body of pancreas (Figure 3d). Read online: Scan this QR code with your smart phone or mobile device to read online. On subsequent probing, the patient provided a history of acute pain in the epigastric region eight weeks prior, which gradually subsided over a few days. Hence, the diagnosis of pancreatic pseudocyst extending to the mediastinum and neck was made. http://www.sajr.org.za Open Access Page 2 of 4 a Case Report c b FIGURE 1: Radiograph of the neck, anteroposterior (a) and lateral (b), demonstrates anterior displacement of the airway and oesophagus (thick arrow) and widening of the prevertebral soft tissue (thin arrow). The frontal chest radiograph (c) indicates displacement of the right paraspinal stripe (thin arrows) and a retrocardiac opacity (thick arrow) indenting (curved arrow) the gastric fundus (asterisk). a b a b c d FIGURE 2: Axial contrast-enhanced CT scan of the neck, at the level of the hyoid bone (a) and at the level of sixth cervical vertebra (b), reveals a peripherally enhancing cystic lesion (thin arrows in a and b) involving the retropharyngeal and prevertebral space with extension to the anterior cervical and visceral space (thick arrow in b). As the patient was symptomatic, the cervical cyst was drained intraorally. Analysis of the aspirate indicated leucocytes and raised amylase levels (55 043 U/L), confirming the diagnosis. The pseudocyst resolved and the patient’s recovery was uneventful. Discussion Pancreatic pseudocysts are common complications of both acute and chronic pancreatitis. The aetiology of pancreatitis and hence pseudocyst includes excessive alcohol consumption, biliary tract pathologies and trauma.1 In the paediatric population, additional causes include genetic abnormalities such as cystic fibrosis, pancreatic anomalies, ingestion of medications such as antiepileptics and metabolic disorders.10 Following an episode of acute pancreatitis, up to four weeks from the onset of pain, fluid collections associated with interstitial oedematous pancreatitis are defined as acute peripancreatic fluid collections according to the revised Atlanta classification for pancreatitis. If the fluid fails to http://www.sajr.org.za FIGURE 3: Axial sections of contrast-enhanced CT scan of the chest and abdomen (a–d) show the pseudocyst in the visceral compartment of the mediastinum abutting the superior vena cava (curved arrow in a) and descending thoracic aorta, with anterior displacement of the oesophagus (curved arrow in c). It is extending into the abdomen through the oesophageal hiatus (white arrow in c) where it is seen arising from the body of pancreas (white arrow in d). Ascites (curved arrow in d), bilateral pleural effusions and left lower lobe consolidation (asterisk in c) are also noted. resorb after four weeks and develops a mature wall, the term pseudocyst is used.11 Pathologically, a pseudocyst of the pancreas cons (...truncated)