Case presentation

A 34-year-old man presented to our urology department in the evening with urinary frequency, gross hematuria, and passage of sand-like material in his urine, which began earlier that morning. He had also experienced fever for three days before presentation.

The patient had smoked five cigarettes per day since the age of 29 years and consumed approximately 10 beers per drinking occasion, approximately 10 times per month. He also had abnormal liver function test results during routine health checkups since that time.

At the age of 31 years (2023), he was admitted to another hospital with acute pancreatitis. During the week preceding the onset of acute pancreatitis, he consumed approximately 10 glasses of highballs daily. Laboratory findings at that time showed an amylase level of 153 U/L, serum calcium of 9.5 mg/dL, IgG4 of 92.7 mg/dL, γ-glutamyl transferase (γ-GTP) of 195 U/L, a white blood cell count of 9,660/μL, and a C-reactive protein level of 0.05 mg/dL (Table 1).

Parameter | Reference range | 2023 (acute pancreatitis) | Current presentation
White blood cell count (/µL) | 3500-9800 | 9660 | 14700
C-reactive protein (mg/dL) | 0-0.30 | 0.05 | 9.89
Amylase (U/L) | 42-132 | 153 | 57
Lipase (U/L) | 13-55 | Not measured | 68
γ-Glutamyl transferase (U/L) | 10-47 | 195 | 95
Calcium (mg/dL) | 8.7-10.3 | 9.5 | 9
Triglycerides (mg/dL) | 30-149 | Not measured | 177
HDL cholesterol (mg/dL) | 40-96 | Not measured | 37
IgG4 (mg/dL) | 11.0-121.0 | 92.7 | 92.9
HbA1c (%) | 4.6-6.2 | Not measured | 5.7
Intact parathyroid hormone (pg/mL) | 10-65 | Not measured | 58

CT and MRCP performed at that time revealed no pancreatic calcifications or apparent pancreatic duct abnormalities (Figures 1, 2).

Figure 1: Noncontrast abdominal CT images obtained during the episode of acute pancreatitis in 2023.(A) Axial and (B) coronal views show no evidence of pancreatic calcification. The yellow arrow indicates the pancreas.

Figure 2: MRCP findings during the episode of acute pancreatitis in 2023.(A) Three-dimensional maximum intensity projection image and (B) axial T2-weighted image demonstrating no significant pancreatic duct dilatation or structural abnormalities. Yellow arrows indicate the main pancreatic duct (Wirsung duct) and the common bile duct (CBD).MRCP, magnetic resonance cholangiopancreatography.

At the current presentation, physical examination revealed no costovertebral angle tenderness but demonstrated perineal tenderness. Laboratory investigations showed a white blood cell count of 14,700/μL, a C-reactive protein level of 9.89 mg/dL, a serum lipase level of 68 U/L, triglycerides of 177 mg/dL, high-density lipoprotein cholesterol of 37 mg/dL, and γ-GTP of 95 U/L. Serum calcium, glycated hemoglobin (HbA1c), IgG, IgG4, and intact parathyroid hormone levels were all within normal ranges.

Urinalysis revealed marked pyuria, and urine culture yielded Escherichia coli, which was susceptible to all tested antimicrobial agents. The patient was diagnosed with acute bacterial prostatitis and treated as an outpatient with intravenous ceftriaxone (2 g/day) and fluid replacement therapy.

Plain abdominal radiography (KUB), performed to evaluate suspected urolithiasis, revealed multiple calcific densities corresponding to the pancreatic region (Figure 3).

Figure 3: Incidental pancreatic calcifications on plain abdominal radiography.Plain abdominal radiography performed for suspected urolithiasis revealed multiple calcific densities in the pancreatic region, leading to an incidental diagnosis of extensively calcified chronic pancreatitis. The yellow arrow indicates pancreatic calcifications.

Noncontrast CT revealed extensive diffuse pancreatic calcifications involving the entire pancreas, accompanied by mild pancreatic enlargement (Figure 4).

Figure 4: Extensive diffuse pancreatic calcifications on noncontrast CT.Noncontrast abdominal CT was performed at presentation. (A) Axial and (B) coronal views demonstrating extensive diffuse calcifications involving the entire pancreas, accompanied by mild pancreatic enlargement. No stones were detected in the urine. The yellow arrows indicate pancreatic calcifications.

Following antimicrobial treatment, the patient’s inflammatory marker levels and urine findings improved by Day 5. He was subsequently switched to oral levofloxacin (500 mg/day), which was prescribed for a total treatment duration of four weeks. He is currently scheduled for a follow-up evaluation at a gastroenterology outpatient clinic.