Thoracic and abdominal pain in a 28-year old woman with a failing kidney transplant

A 28-year old woman with a failing kidney transplant due to rejection (on high dose Prednisolone and Alemtuzumab) presented with increasing right-sided thoracic pain and abdominal discomfort. Physical examination revealed no abnormalities. Laboratory results showed a normal white blood cell count, low serum C-reactive protein, normal level of liver enzymes and electrolytes, an elevated serum creatinine of 335 μmol/L consistent with known chronic kidney transplant failure and a mildly elevated lipase of 360 U/L. Initial diagnostic workup excluded a pulmonary embolism, pneumonia, cardiac ischaemia, urinary tract infection, choledocholithiasis and cholecystitis. In the days following admission the patient developed intense epigastric pain and serum lipase increased to >3x upper limit of the reference range (3002 U/L). Oesophago-gastro-duodenoscopy showed mild antrum gastritis and multiple small white lesions (Figure 1). A CT scan of the abdomen showed multiple pancreatic cysts (Figure 2), and nodular densities with ground glass consolidations in the included basal lung fields (Figure 3).

Arrows denote the relevant lesions.What is the unifying diagnosis?

Kirill Pavlov1, Parweez Koehestanie1, Jaap J. Beutler2, Tessa E. H. Römkens1, Ellen K. Hoogeveen2, Loes H.C. Nissen1

1 Department of gastroenterology and hepatology, Jeroen Bosch Ziekenhuis (Jeroen Bosch hospital) Den Bosch, the Netherlands

2 Department of internal medicine, Jeroen Bosch Ziekenhuis (Jeroen Bosch hospital) Den Bosch, the Netherlands