Pancreatic Malakoplakia in a Patient with Chronic Pancreatitis: A Case Report

Pancreatic Malakoplakia in a Patient with Chronic Pancreatitis: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Pancreatic Malakoplakia in a Patient with Chronic Pancreatitis: A Case Report Lilong Guo, David Lewin, Chadi Hajar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9185931/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Introduction : Malakoplakia is a granulomatous disease that most frequently involves the genitourinary system and is commonly associated with immunosuppressed patients. However, these lesions can affect other organs, including the pancreas. Its presentation can mimic other pancreatic pathologies, such as neoplasms or chronic pancreatitis, making its diagnosis challenging. Early and precise diagnosis of the disease may avoid unnecessary surgery and improve outcomes. Patient presentation : A 39-year-old woman who presented with abdominal pain underwent a distal pancreatectomy and splenectomy, and the pathology revealed rare malakoplakia in the context of chronic pancreatitis. Notably, the patient had no immunosuppression or infection. Conclusion : We report a rare case of pancreatic malakoplakia in a patient with no immunosuppression or infection to raise awareness of this condition and further reviewing findings from previously reported cases of pancreatic malakoplakia in the literature. Pancreatic malakoplakia Michaelis-Gutmann bodies von Kossa’s staining Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Malakoplakia, characterized by defective phagolysosomal function in macrophages, is a granulomatous disease. The term “Malakoplakia,” first coined by von Hansemann in 1903, means “soft plaque”[ 1 ]. The pathognomonic histological feature of malakoplakia is the presence of Michaelis-Gutmann bodies, which were first identified and described by Michaelis and Gutmann in 1902[ 2 ]. Malakoplakia most commonly affects the urinary tract in immunocompromised individuals but has also been reported in those with a normal immune system, as well as in other organs, such as the gastrointestinal tract, lungs, and skin[ 3 – 8 ]. Pancreatic involvement is extremely rare, with only a few cases documented in the literature. This case report describes a 39-year-old woman with a background of chronic pancreatitis and no immunosuppression who was diagnosed with pancreatic malakoplakia following distal pancreatectomy and splenectomy. The objective of this report is to raise awareness of this rare pathology and its diagnostic challenges, particularly in patients with underlying pancreatic conditions, and to review previously reported cases of pancreatic malakoplakia in English-language literatures. Case Presentation An afebrile 39-year-old woman with a history of alcoholic pancreatitis and gastroesophageal reflux disease (GERD) presented to our institute with diffuse, paroxysmal abdominal pain, which occurred 2–3 times per week and was exacerbated by eating. The patient had remained sober for 28 days since the onset of her symptoms. Physical examination revealed mild tenderness in the upper abdomen. Lactate: 3.6 mmol/L (0.5–1.6 mmol/L); WBC: 21.84 k/cumm (4.8–10.8 k/cumm); hemoglobin: 11.4 gm/dL (12.0–16.0 gm/dL); platelets: 55 k/cumm (140–440 k/cumm); Glucose: 206 mg/dL (70–100 mg/dL). There was no evidence of an underlying immunocompromised state. Blood culture and urinalysis were negative for bacteria or yeast. Contrast-enhanced CT of the abdomen revealed thick-walled fluid collections measuring 4.8 × 5.1 cm inferior to the body and tail of the pancreas, with an additional 1.2 cm pseudocyst superior to the pancreatic tail (Fig. 1 ). The patient underwent distal pancreatectomy and splenectomy due to concerns of severe chronic pancreatitis with possible necrosis. Intraoperative findings include extensive chronic pancreatitis with necrotic areas. There were no visible pancreatic masses or obvious malignancies. On gross examination of the pancreatic specimen, the surface was fibrotic, with a soft, necrotic area abutting the resection margin measuring 2.0 × 1.3 × 1.0 cm. On light microscopy, sections from the pancreatic tail revealed extensive malakoplakia characterized by sheets of histiocytes containing basophilic Michaelis-Gutmann bodies (Figs. 3 & 4 ), with a background of chronic pancreatitis (Fig. 2 ). At the 3-month follow-up, the patient reported significant improvement in her symptoms, with no further episodes of abdominal pain. Discussion Malakoplakia is characterized by defective phagolysosomal activity. The undigested bacterial fragments eventually become mineralized with iron and calcium phosphate, reflected by targetoid, PAS-D-positive Michaelis-Gutmann (MG) bodies. They represent calcified lysosomes containing bacterial remnants. Von Kossa’s staining is the most common method to highlight these intracytoplasmic inclusions[ 3 ]. In previously reported cases (Table 1 ), five out of eight showed bacterial infection, most commonly Escherichia coli infection [ 9 – 13 ], although Klebsiella sp., Corynebacterium Equi, Streptococcus salivarius , and Enterococcus faecium have also been reported. Two patients experienced significant reduction or resolution of pancreatic masses with conservative antibiotic treatment, underscoring the benign nature of malakoplakia[ 9 , 12 ]. One patient had biopsy-confirmed malakoplakia and serology evidence of infection, emphasizing the importance of biopsy for management [ 12 ]. Despite its benign nature, five patients underwent surgery [ 14 , 10 , 15 , 11 , 13 ], with four involving pancreatectomy[ 14 , 10 , 11 , 13 ]. Notably, one of the four patients with FNA-confirmed malakoplakia underwent Whipple’s procedure due to disease progression regardless of antibiotic treatment[ 11 ], suggesting the limits of conservative therapy. Although, malakoplakia is considered a benign process; the treatment should be customized according to specific clinical scenario. If a patient is stable, biopsy may be more beneficial as it might avoid invasive therapy overall. Table 1 Summary of Pancreatic Malakoplakia in English-Language Literature Malakoplakia in pancreas Author Age Gender Imaging Site Malignancy Immunodeficiency Infection Other features Treatment Clinical outcome FNA or Biopsy Zuk,R.J., et al[ 14 ] 1990 45 F CT: a probable pancreatic neoplasm Head of pancreas a Moderately well-differentiated adenocarcinoma No No Metastasized to liver post Whipple’s surgery Whipple’s procedure Died due to metastasis to liver No Sinclair-Smith, C., et al[ 17 ] 1975 6 weeks M None given Adrenal and colon with spread into tail of pancreas b No Yes No Systemic involvement: Thymic and lymphoid hypoplasia None given Died of miliary TB No Colby, T.V.[ 10 ] 1978 49 M None given 8-cm-diameter left retroperitoneal mass invading the tail of the pancreas b No suspicious Yes, Klebsiella sp. In addition, corynebacterium Equi. in biopsies Systemic involvement: Weight loss and anemia laparotomy Recurrence of malakoplakia in right greater trochanter No Kulatunga, A., et al[ 15 ] 1987 75 M None given 8 X 9 cm mass in caudal region of the pancreas a No No No Lesion identified at elective cholecystectomy Cholecystectomy and mass resection, pancreas reserved. No complications FNA Guha, S., et al[ 11 ] 2015 59 M Endoscopic ultrasound: 33 X 32 mm mass Head of the pancreas a No No Yes, E. coli in ascites Systemic involvement: Abdominal pain, fatigue, and weight loss Whipple’s procedure Recurrent ascites post-surgery without additional imaging abnormalities. No Nuciforo, P.G., et al[ 13 ] 2003 74 M CT and MRI: ovoidal mass measuring 4x 2 cm Isthmus and the tail of the pancreas a No No Yes, TEM showing bacterial-like structures History of DM. Low grade fever and abdominal pain Distal spleno-pancreatectomy with multiple lymph-node dissection No complications Core needle biopsy Hubbard, L., et al[ 12 ] 2020 66 M MRI: 10.3 cm mass Head of the pancreas and duodenum a No Yes Yes, Escherichia coli , streptococcus salivarius group Systemic involvement: weight loss, fatigue s/p orthotopic heart transplantation Ceftriaxone and metronidazole Mass volume significantly decreased from 249 ml to 63 ml after 10 weeks No Afzal, R.M., et al[ 9 ] 2023 74 M CT: infiltrating mass Head of the pancreas a No No Yes, E. coli and Enterococcus faecium in biopsies. Fevers, chills, pseudocyst in pancreatic head Amoxicillin-clavulanate Mass eventual resolved 1 year later No Lilong G, et al Present study 39 F CT: fluid collections measuring 4.8 x 5.1 cm Body and tail of the pancreas a No No No Abdominal pain, Pseudocyst in pancreatic tail pancreatectomy and splenectomy No complications No a. Primary pancreatic involvement b. Secondary pancreatic involvement Among the eight documented cases, five were found to involve primarily the pancreas[ 9 , 11 , 12 , 15 , 13 , 14 ], similar to our case, which developed in the context of chronic pancreatitis and pseudocyst formation. Interestingly, one patient presented with moderately well-differentiated pancreatic adenocarcinoma, suggesting that malakoplakia can be associated with malignancy [ 14 ]. This association has been documented in the gastrointestinal tract, liver, and stomach[ 16 ]. The development of malakoplakia in patients with malignancies may be a histiocytic response to cancer or inflammation, although the exact cellular mechanisms involved remain unclear. In our review, with the exception of one patient with malignancy[ 14 ], two patients were immunosuppressed, and one was born with thymic and lymphoid hypoplasia[ 17 , 12 ]. The immunosuppressed state associated with malignancy may play a role in the development of malakoplakia. As our patient was not immunosuppressed, showed no evidence of infection, remained afebrile, had negative blood culture and uranalysis, and did not receive antibiotic treatment, the pathogenesis of malakoplakia was unclear. Although the likelihood of an underlying malignancy in our patient was low, comprehensive evaluation of the lesions was undertaken to exclude a coexistent neoplasm. The exclusion of malignancy is imperative before pursuing a non-surgical management strategy in such cases given the association between malakoplakia with neoplasm[ 18 , 19 ]. Lastly, it is essential to raise awareness among surgeons that pancreatic malakoplakia, although exceedingly rare, should be considered in the differential diagnosis in patients with chronic pancreatitis and possible pancreatic pseudocysts. Malakoplakia often presents as a mass, mimicking cancer and complicating the diagnosis, especially when it is extensive or accompanied by systemic symptoms. Four patients presented with systemic symptoms such as weight loss, anemia, fatigue, and low-grade fever[ 10 – 12 , 17 ]. One patient even experienced recurrence at another site later in life[ 10 ]. The imaging findings could be very predictable on magnetic resonance (MR) which would be expected of a granulomatous mass, resulting from abundant foamy histiocytic reaction[ 12 , 20 – 22 ]. However, our case differed in that no mass was observed, and imaging revealed a pseudocystic lesion with possible necrosis. Overall, based on the clinicopathologic analysis of nine cases here, preoperative suspicion for malakoplakia should be amplified when a constellation of clinical and radiological findings is present including immunosuppressed status, recurrent and resistant infections- particularly E. coli or gram-negative bacteria- and presence of mass lesion on imaging studies. Although these features may raise clinical concerns for malakoplakia, a definitive diagnosis relies on histopathological evaluation of sampled tissue. When it comes to differential diagnoses, conditions characterized by histiocytic or granulomatous infiltration should also be considered. Chronic granulomatous inflammation such as mycobacterial and fungal infections, can frequently mimic the entity, as these lesions often exhibit aggregates of epithelioid cells and giant cells. However, they lack the diagnostic Michaelis–Gutmann bodies. Additionally, nonspecific histiocytic infiltrates within the wall of a pseudocyst can also resemble malakoplakia, but they do not display the characteristic inclusions. Rosai–Dorfman disease may enter the differential due to its histiocytic proliferation, but it is distinguished by the hallmark features of emperipolesis and by the presence of enlarged non-Langerhans histiocytes with abundant eosinophilic cytoplasm, oval nuclei, and prominent nucleoli rather than foamy histiocytes with laminated inclusions. Rarely, signet ring cell carcinoma can mimic malakoplakia when malignant cells with cytoplasmic mucin droplets form targetoid inclusion. Nonetheless, the presence of nuclear atypia and epithelial marker expression facilitates accurate distinction. Furthermore, metastatic clear cell renal cell carcinoma may mimic the foamy histiocytes of malakoplakia due to its clear cytoplasmic morphology. However, careful evaluation of cytologic atypia and immunohistochemistry allows separation of the two. Conclusion Pancreatic malakoplakia is a rare but significant differential diagnosis in patients with chronic pancreatitis who present with mass-like lesions or pseudocysts. This case highlights the diagnostic challenges and the importance of histopathological confirmation. A review of previously reported cases in English-language literature underscores the complexity of treatment and etiology. Abbreviations GERD gastroesophageal reflux disease WBC white blood cell CT computed tomography PAS-D periodic acid-Schiff with diastase FNA fine-needle aspiration MR magnetic resonance MRI magnetic resonance imaging Declarations i. Funding: Not applicable ii. Conflicts of interest/Competing interests: Author Lilong G., Author David L., and Author Chadi H. declare that they have no conflicts of interest. iii. Ethics approval: All procedures performed in studies involving human participants were in accordance. with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards iv. Consent to participate: Informed consent was obtained from all individual participants included in the study. v. Written Consent for publication : Informed consent was obtained from all individual authors and patients included in the study. vi. Availability of data and material: Not applicable vii. Code availability: Not applicable viii. Authors' contributions: Author L.G. collected the data and drafted the manuscript; Author D.L. contributed to the revision; Author C.H. contributed to the analysis and revision of the manuscript. References Bon Hansemann D. (1903). über malakoplakie der harnblase. Virchows Archiv für pathologische Anatomie und Physiologie und für klinische Medizin, 173 , 302–308. https://doi.org/10.1007/BF01944507 Michaelis LaG, C. UbreEinschlusse in Blasentumore. Klin Med. 1902;47:208. Lewin KJ, Fair WR, Steigbigel RT, Winberg CD, Droller MJ. Clinical and laboratory studies into the pathogenesis of malacoplakia. J Clin Pathol. 1976;29(4):354–63. 10.1136/jcp.29.4.354 . Benites-Goni H, Sanchez K, Orellana MDC, L., Marin Calderon L. A rare case of colonic malakoplakia at the bottom of an adenoma mimicking an invasive carcinoma. Rev Esp Enferm Dig. 2023. 10.17235/reed.2023.9994/2023 . Benlghazi A, Benali S, Belouad M, Ait Bouhou R, Hassani E, M. M., Kouach J. Malakoplakia mimicking malignant ovarian tumor: A case report and literature review. Int J Surg Case Rep. 2023;112:109012. 10.1016/j.ijscr.2023.109012 . Gerard A, Mesa H, Danziger-Isakov L, Barros KL, Alali M. Successful treatment of malakoplakia of the liver and skin in a pediatric liver transplant patient. Pediatr Transpl. 2023;27(5):e14492. 10.1111/petr.14492 . Grewal HS, Virk RK, Carroll ME, Benvenuto LJ, Robbins H, Shah L, et al. Malakoplakia Presenting as a Lung Mass in a Lung Transplant Recipient: Case Report. Transpl Proc. 2022;54(1):173–5. 10.1016/j.transproceed.2021.11.013 . Taher M, Shahsia R, Ebrahimi Daryani N. Malakoplakia as a Rare Cause of Diarrhea: Case Presentation and Review of Literature. Middle East J Dig Dis. 2021;13(1):71–4. 10.34172/mejdd.2021.207 . Afzal RM, Rangaswamy B, Landau M, John I, Singh H, Phillips AE. Pancreatic Malakoplakia: A Rare Pathology Associated With Acute Pancreatitis. ACG Case Rep J. 2023;10(4):e01042. 10.14309/crj.0000000000001042 . Colby TV. Malakoplakia. Two unusual cases which presented diagnostic problems. Am J Surg Pathol. 1978;2(4):377–82. Guha S, Liu H. (2015). Malakoplakia of the Pancreas with Simultaneous Colon Involvement: Case Report and Review of the Literature. Case Rep Pathol, 2015 , 649136. 10.1155/2015/649136 Hubbard L, Iriana S, Carey A, Odrobina R, Sossenheimer M, Rogers D. Radiographic and Endoscopic Features of Pancreaticoduodenal Malakoplakia. Pancreas. 2020;49(3):455–60. 10.1097/mpa.0000000000001497 . Nuciforo PG, Moneghini L, Braidotti P, Castoldi L, De Rai P, Bosari S. Malakoplakia of the pancreas with diffuse lymph-node involvement. Virchows Arch. 2003;442(1):82–5. 10.1007/s00428-002-0727-5 . Zuk RJ, Neal JW, Baithun SI. Malakoplakia of the pancreas. Virchows Arch Pathol Anat Histopathol. 1990;417(2):181–4. 10.1007/BF02190538 . Kulatunga A, Kyllonen AP, Dammert K. Malakoplakia of the pancreas. A case report. Acta Pathol Microbiol Immunol Scand A. 1987;95(3):127–9. 10.1111/j.1699-0463.1987.tb00018_95a.x . Lee M, Ko HM, Rubino A, Lee H, Gill R, Lagana SM. Malakoplakia of the gastrointestinal tract: clinicopathologic analysis of 23 cases. Diagn Pathol. 2020;15(1):97. 10.1186/s13000-020-01013-y . Sinclair-Smith C, Kahn LB, Cywes S. Malacoplakia in childhood. Case report with ultrastructural observations and review of the literature. Arch Pathol. 1975;99(4):198–203. Andres L, Etxegarai L, Lopez JI, Oleaga L, Bilbao FJ, Ereno C. Malakoplakia associated with colorectal adenocarcinoma. Ann Saudi Med. 2005;25(1):50–2. 10.5144/0256-4947.2005.50 . Lew S, Siegal A, Aronheim M. Renal cell carcinoma with malakoplakia. Eur Urol. 1988;14(5):426–8. 10.1159/000472998 . Hina S, Hasan A, Iqbal N, Shabbir MU, Sheikh AAE. Malakoplakia of the Urinary Bladder and Unilateral Ureter. J Coll Physicians Surg Pak. 2019;29(6):582–4. 10.29271/jcpsp.2019.06.582 . Wong-You-Cheong JJ, Woodward PJ, Manning MA, Davis CJ. From the archives of the AFIP: Inflammatory and nonneoplastic bladder masses: radiologic-pathologic correlation. Radiographics. 2006;26(6):1847–68. 10.1148/rg.266065126 . Fudaba H, Ooba H, Abe T, Kamida T, Wakabayashi Y, Nagatomi H, et al. An adult case of cerebral malakoplakia successfully cured by treatment with antibiotics, bethanechol and ascorbic acid. J Neurol Sci. 2014;342(1–2):192–6. 10.1016/j.jns.2014.05.006 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 04 Apr, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers invited by journal 25 Mar, 2026 Editor assigned by journal 24 Mar, 2026 Submission checks completed at journal 24 Mar, 2026 First submitted to journal 21 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9185931","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":612449139,"identity":"42afe88a-9c44-4ebc-a4f1-594244147fa5","order_by":0,"name":"Lilong Guo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApUlEQVRIiWNgGAWjYHACxgMfoCwJovUcnEGylsM8JGmRj0g+cNg257A9fwPzwds8hDUwMBjeSEs4nLvtcOKMA2zJ1sRpmZFjANKSYMDAYyZNvBbLbYftDRj4vxGnRV4CqIVx22HGDQw8bMRpMeB5lnCwd1t64ozDbMaWc4iypT354IOf26zt+dubH954Q5QtB2AsZmKUg21pIFblKBgFo2AUjFwAAFykMJWJOeEfAAAAAElFTkSuQmCC","orcid":"","institution":"Medical University of South Carolina","correspondingAuthor":true,"prefix":"","firstName":"Lilong","middleName":"","lastName":"Guo","suffix":""},{"id":612449140,"identity":"0e1c6f79-0062-4835-baa3-0096e4aa6b01","order_by":1,"name":"David Lewin","email":"","orcid":"","institution":"Medical University of South Carolina","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Lewin","suffix":""},{"id":612449141,"identity":"349e0082-eb41-4221-92b5-dfe4fc7877da","order_by":2,"name":"Chadi Hajar","email":"","orcid":"","institution":"Medical University of South Carolina","correspondingAuthor":false,"prefix":"","firstName":"Chadi","middleName":"","lastName":"Hajar","suffix":""}],"badges":[],"createdAt":"2026-03-21 13:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9185931/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9185931/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105572724,"identity":"7a24dcee-973b-4a69-a5fe-eb46b81cda48","added_by":"auto","created_at":"2026-03-27 13:29:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":321505,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal CT revealed athick-walled, amorphous collection inferior to the body and tail of the pancreas measured 4.8 ×5.1 cm (A). Additionally,1.2 cm of fluid was collected superior to the tail of the pancreas (B).\u003c/p\u003e","description":"","filename":"GuoFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9185931/v1/db237ae589fefe809ee96c0b.png"},{"id":105572172,"identity":"063a4673-2e1f-4e63-bbde-e2844326ea35","added_by":"auto","created_at":"2026-03-27 13:25:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":910773,"visible":true,"origin":"","legend":"\u003cp\u003eHistological examination (H\u0026amp;E) revealed chronic pancreatitis with intralobular fibrosis, loss of acinar tissue (A, 5X; B, 10X) and pseudocyst formation with crystal clefts and inflammatory infiltration in the cyst wall (C, 2X; D, 10X).\u003c/p\u003e","description":"","filename":"GuoFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9185931/v1/a4e9ed679f157a960c2ef784.png"},{"id":105573477,"identity":"ca4eb898-f441-4859-b1f7-053639a982a9","added_by":"auto","created_at":"2026-03-27 13:31:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":649180,"visible":true,"origin":"","legend":"\u003cp\u003eThe H\u0026amp;E section demonstrates targetoid histiocytes (arrows); von Kossa staining highlights diffuse intracytoplasmic targetoid inclusions (arrowheads) known as Michaelis-Gutmann bodies. (A, H\u0026amp;E, 40X; B, von Kossa stain, 40X).\u003c/p\u003e","description":"","filename":"GuoFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9185931/v1/eb43f076ea624d989d31cfe1.png"},{"id":105571406,"identity":"41a59ca2-2020-4f59-a1a0-0b770209ccfb","added_by":"auto","created_at":"2026-03-27 13:23:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":669137,"visible":true,"origin":"","legend":"\u003cp\u003eHistological examination (H\u0026amp;E) revealed chronic pancreatitis with intralobular fibrosis, loss of acinar tissue (A, 5X; B, 10X) and pseudocyst formation with crystal clefts and inflammatory infiltration in the cyst wall (C, 2X; D, 10X).\u003c/p\u003e","description":"","filename":"GuoFigure4.png","url":"https://assets-eu.researchsquare.com/files/rs-9185931/v1/647efff65e56a6d8d50f7342.png"},{"id":105575499,"identity":"e58f8586-43a9-42ef-a3a6-81faa738d39d","added_by":"auto","created_at":"2026-03-27 13:39:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3398660,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9185931/v1/a22b4935-dbbe-4f1c-9ea0-e80cbd7628de.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePancreatic Malakoplakia in a Patient with Chronic Pancreatitis: A Case Report\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalakoplakia, characterized by defective phagolysosomal function in macrophages, is a granulomatous disease. The term \u0026ldquo;Malakoplakia,\u0026rdquo; first coined by von Hansemann in 1903, means \u0026ldquo;soft plaque\u0026rdquo;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The pathognomonic histological feature of malakoplakia is the presence of Michaelis-Gutmann bodies, which were first identified and described by Michaelis and Gutmann in 1902[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMalakoplakia most commonly affects the urinary tract in immunocompromised individuals but has also been reported in those with a normal immune system, as well as in other organs, such as the gastrointestinal tract, lungs, and skin[\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Pancreatic involvement is extremely rare, with only a few cases documented in the literature.\u003c/p\u003e \u003cp\u003eThis case report describes a 39-year-old woman with a background of chronic pancreatitis and no immunosuppression who was diagnosed with pancreatic malakoplakia following distal pancreatectomy and splenectomy. The objective of this report is to raise awareness of this rare pathology and its diagnostic challenges, particularly in patients with underlying pancreatic conditions, and to review previously reported cases of pancreatic malakoplakia in English-language literatures.\u003c/p\u003e "},{"header":"Case Presentation","content":"\u003cp\u003eAn afebrile 39-year-old woman with a history of alcoholic pancreatitis and gastroesophageal reflux disease (GERD) presented to our institute with diffuse, paroxysmal abdominal pain, which occurred 2\u0026ndash;3 times per week and was exacerbated by eating. The patient had remained sober for 28 days since the onset of her symptoms. Physical examination revealed mild tenderness in the upper abdomen. Lactate: 3.6 mmol/L (0.5\u0026ndash;1.6 mmol/L); WBC: 21.84 k/cumm (4.8\u0026ndash;10.8 k/cumm); hemoglobin: 11.4 gm/dL (12.0\u0026ndash;16.0 gm/dL); platelets: 55 k/cumm (140\u0026ndash;440 k/cumm); Glucose: 206 mg/dL (70\u0026ndash;100 mg/dL). There was no evidence of an underlying immunocompromised state. Blood culture and urinalysis were negative for bacteria or yeast. Contrast-enhanced CT of the abdomen revealed thick-walled fluid collections measuring 4.8 \u0026times; 5.1 cm inferior to the body and tail of the pancreas, with an additional 1.2 cm pseudocyst superior to the pancreatic tail (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient underwent distal pancreatectomy and splenectomy due to concerns of severe chronic pancreatitis with possible necrosis. Intraoperative findings include extensive chronic pancreatitis with necrotic areas. There were no visible pancreatic masses or obvious malignancies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn gross examination of the pancreatic specimen, the surface was fibrotic, with a soft, necrotic area abutting the resection margin measuring 2.0 \u0026times; 1.3 \u0026times; 1.0 cm. On light microscopy, sections from the pancreatic tail revealed extensive malakoplakia characterized by sheets of histiocytes containing basophilic Michaelis-Gutmann bodies (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026amp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), with a background of chronic pancreatitis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt the 3-month follow-up, the patient reported significant improvement in her symptoms, with no further episodes of abdominal pain.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMalakoplakia is characterized by defective phagolysosomal activity. The undigested bacterial fragments eventually become mineralized with iron and calcium phosphate, reflected by targetoid, PAS-D-positive Michaelis-Gutmann (MG) bodies. They represent calcified lysosomes containing bacterial remnants. Von Kossa\u0026rsquo;s staining is the most common method to highlight these intracytoplasmic inclusions[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In previously reported cases (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), five out of eight showed bacterial infection, most commonly \u003cem\u003eEscherichia coli\u003c/em\u003e infection [\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], although \u003cem\u003eKlebsiella sp., Corynebacterium Equi, Streptococcus salivarius\u003c/em\u003e, \u003cem\u003eand Enterococcus faecium\u003c/em\u003e have also been reported. Two patients experienced significant reduction or resolution of pancreatic masses with conservative antibiotic treatment, underscoring the benign nature of malakoplakia[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. One patient had biopsy-confirmed malakoplakia and serology evidence of infection, emphasizing the importance of biopsy for management [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite its benign nature, five patients underwent surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], with four involving pancreatectomy[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Notably, one of the four patients with FNA-confirmed malakoplakia underwent Whipple\u0026rsquo;s procedure due to disease progression regardless of antibiotic treatment[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], suggesting the limits of conservative therapy. Although, malakoplakia is considered a benign process; the treatment should be customized according to specific clinical scenario. If a patient is stable, biopsy may be more beneficial as it might avoid invasive therapy overall.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Pancreatic Malakoplakia in English-Language Literature\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"12\" nameend=\"c12\" namest=\"c1\"\u003e \u003cp\u003eMalakoplakia in pancreas\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMalignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmunodeficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOther features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eClinical outcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eFNA or Biopsy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZuk,R.J., et al[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e1990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT: a probable pancreatic neoplasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHead of pancreas \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerately well-differentiated adenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMetastasized to liver post Whipple\u0026rsquo;s surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhipple\u0026rsquo;s procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDied due to metastasis to liver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinclair-Smith, C., et al[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e1975\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone given\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdrenal and colon with spread into tail of pancreas \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSystemic involvement: Thymic and lymphoid hypoplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNone given\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDied of miliary TB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColby, T.V.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e1978\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone given\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8-cm-diameter left retroperitoneal mass invading the tail of the pancreas \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003esuspicious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes, \u003cem\u003eKlebsiella\u003c/em\u003e sp. In addition, \u003cem\u003ecorynebacterium Equi.\u003c/em\u003e in biopsies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSystemic involvement: Weight loss and anemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003elaparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRecurrence of malakoplakia in right greater trochanter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKulatunga, A., et al[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e1987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone given\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 X 9 cm mass in caudal region of the pancreas \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLesion identified at elective cholecystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCholecystectomy and mass resection, pancreas reserved.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eFNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuha, S., et al[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndoscopic ultrasound: 33 X 32 mm mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHead of the pancreas \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes, \u003cem\u003eE. coli\u003c/em\u003e in ascites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSystemic involvement: Abdominal pain, fatigue, and weight loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhipple\u0026rsquo;s procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRecurrent ascites post-surgery without additional imaging abnormalities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuciforo, P.G., et al[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e2003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT and MRI: ovoidal mass measuring 4x 2 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIsthmus and the tail of the pancreas \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes, TEM showing bacterial-like structures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHistory of DM. Low grade fever and abdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDistal spleno-pancreatectomy with multiple lymph-node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eCore needle biopsy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHubbard, L., et al[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMRI: 10.3 cm mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHead of the pancreas and duodenum \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes, \u003cem\u003eEscherichia coli\u003c/em\u003e, streptococcus salivarius group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSystemic involvement: weight loss, fatigue\u003c/p\u003e \u003cp\u003es/p orthotopic heart transplantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCeftriaxone and metronidazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMass volume significantly decreased from 249 ml to 63 ml after 10 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfzal, R.M., et al[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT: infiltrating mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHead of the pancreas \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes, \u003cem\u003eE. coli\u003c/em\u003e and \u003cem\u003eEnterococcus faecium\u003c/em\u003e in biopsies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFevers, chills, pseudocyst in pancreatic head\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAmoxicillin-clavulanate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMass eventual resolved 1 year later\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLilong G, et al\u003c/p\u003e \u003cp\u003ePresent study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT: fluid collections measuring 4.8 x 5.1 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBody and tail of the pancreas \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAbdominal pain,\u003c/p\u003e \u003cp\u003ePseudocyst in pancreatic tail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003epancreatectomy and splenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003ea. Primary pancreatic involvement\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eb. Secondary pancreatic involvement\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong the eight documented cases, five were found to involve primarily the pancreas[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], similar to our case, which developed in the context of chronic pancreatitis and pseudocyst formation. Interestingly, one patient presented with moderately well-differentiated pancreatic adenocarcinoma, suggesting that malakoplakia can be associated with malignancy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This association has been documented in the gastrointestinal tract, liver, and stomach[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The development of malakoplakia in patients with malignancies may be a histiocytic response to cancer or inflammation, although the exact cellular mechanisms involved remain unclear. In our review, with the exception of one patient with malignancy[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], two patients were immunosuppressed, and one was born with thymic and lymphoid hypoplasia[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The immunosuppressed state associated with malignancy may play a role in the development of malakoplakia. As our patient was not immunosuppressed, showed no evidence of infection, remained afebrile, had negative blood culture and uranalysis, and did not receive antibiotic treatment, the pathogenesis of malakoplakia was unclear. Although the likelihood of an underlying malignancy in our patient was low, comprehensive evaluation of the lesions was undertaken to exclude a coexistent neoplasm. The exclusion of malignancy is imperative before pursuing a non-surgical management strategy in such cases given the association between malakoplakia with neoplasm[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Lastly, it is essential to raise awareness among surgeons that pancreatic malakoplakia, although exceedingly rare, should be considered in the differential diagnosis in patients with chronic pancreatitis and possible pancreatic pseudocysts.\u003c/p\u003e \u003cp\u003eMalakoplakia often presents as a mass, mimicking cancer and complicating the diagnosis, especially when it is extensive or accompanied by systemic symptoms. Four patients presented with systemic symptoms such as weight loss, anemia, fatigue, and low-grade fever[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. One patient even experienced recurrence at another site later in life[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The imaging findings could be very predictable on magnetic resonance (MR) which would be expected of a granulomatous mass, resulting from abundant foamy histiocytic reaction[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, our case differed in that no mass was observed, and imaging revealed a pseudocystic lesion with possible necrosis.\u003c/p\u003e \u003cp\u003eOverall, based on the clinicopathologic analysis of nine cases here, preoperative suspicion for malakoplakia should be amplified when a constellation of clinical and radiological findings is present including immunosuppressed status, recurrent and resistant infections- particularly \u003cem\u003eE. coli\u003c/em\u003e or gram-negative bacteria- and presence of mass lesion on imaging studies. Although these features may raise clinical concerns for malakoplakia, a definitive diagnosis relies on histopathological evaluation of sampled tissue.\u003c/p\u003e \u003cp\u003eWhen it comes to differential diagnoses, conditions characterized by histiocytic or granulomatous infiltration should also be considered. Chronic granulomatous inflammation such as mycobacterial and fungal infections, can frequently mimic the entity, as these lesions often exhibit aggregates of epithelioid cells and giant cells. However, they lack the diagnostic Michaelis\u0026ndash;Gutmann bodies. Additionally, nonspecific histiocytic infiltrates within the wall of a pseudocyst can also resemble malakoplakia, but they do not display the characteristic inclusions. Rosai\u0026ndash;Dorfman disease may enter the differential due to its histiocytic proliferation, but it is distinguished by the hallmark features of emperipolesis and by the presence of enlarged non-Langerhans histiocytes with abundant eosinophilic cytoplasm, oval nuclei, and prominent nucleoli rather than foamy histiocytes with laminated inclusions. Rarely, signet ring cell carcinoma can mimic malakoplakia when malignant cells with cytoplasmic mucin droplets form targetoid inclusion. Nonetheless, the presence of nuclear atypia and epithelial marker expression facilitates accurate distinction. Furthermore, metastatic clear cell renal cell carcinoma may mimic the foamy histiocytes of malakoplakia due to its clear cytoplasmic morphology. However, careful evaluation of cytologic atypia and immunohistochemistry allows separation of the two.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePancreatic malakoplakia is a rare but significant differential diagnosis in patients with chronic pancreatitis who present with mass-like lesions or pseudocysts. This case highlights the diagnostic challenges and the importance of histopathological confirmation. A review of previously reported cases in English-language literature underscores the complexity of treatment and etiology.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGERD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egastroesophageal reflux disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ewhite blood cell\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAS-D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eperiodic acid-Schiff with diastase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFNA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efine-needle aspiration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003ei. \u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eii. \u003cstrong\u003eConflicts of interest/Competing interests:\u0026nbsp;\u003c/strong\u003eAuthor Lilong G., Author David L., and Author Chadi H. declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eiii. \u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eAll procedures performed in studies involving human participants were in accordance. with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards\u003c/p\u003e\n\u003cp\u003eiv. \u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003ev. \u003cstrong\u003eWritten Consent for publication\u003c/strong\u003e: Informed consent was obtained from all individual authors and patients included in the study.\u003c/p\u003e\n\u003cp\u003evi. \u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003evii. \u003cstrong\u003eCode availability:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eviii. \u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eAuthor L.G. collected the data and drafted the manuscript; Author D.L. contributed to the revision; Author C.H. contributed to the analysis and revision of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBon Hansemann D. 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An adult case of cerebral malakoplakia successfully cured by treatment with antibiotics, bethanechol and ascorbic acid. J Neurol Sci. 2014;342(1\u0026ndash;2):192\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jns.2014.05.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jns.2014.05.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pancreatic malakoplakia, Michaelis-Gutmann bodies, von Kossa’s staining","lastPublishedDoi":"10.21203/rs.3.rs-9185931/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9185931/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Malakoplakia is a granulomatous disease that most frequently involves the genitourinary system and is commonly associated with immunosuppressed patients. However, these lesions can affect other organs, including the pancreas. Its presentation can mimic other pancreatic pathologies, such as neoplasms or chronic pancreatitis, making its diagnosis challenging. Early and precise diagnosis of the disease may avoid unnecessary surgery and improve outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient presentation\u003c/strong\u003e: A 39-year-old woman who presented with abdominal pain underwent a distal pancreatectomy and splenectomy, and the pathology revealed rare malakoplakia in the context of chronic pancreatitis. Notably, the patient had no immunosuppression or infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: We report a rare case of pancreatic malakoplakia in a patient with no immunosuppression or infection to raise awareness of this condition and further reviewing findings from previously reported cases of pancreatic malakoplakia in the literature.\u003c/p\u003e","manuscriptTitle":"Pancreatic Malakoplakia in a Patient with Chronic Pancreatitis: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-27 12:29:18","doi":"10.21203/rs.3.rs-9185931/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-04T10:38:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50866028454363188504921560375336806400","date":"2026-03-30T10:46:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310469343549180182833066612626280153790","date":"2026-03-25T12:51:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301156678207454712486230100931608660611","date":"2026-03-25T08:12:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-25T08:01:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-24T10:12:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T09:02:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2026-03-21T12:56:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a669faf3-2ac5-417f-9ac0-c5e7cb5ca7b7","owner":[],"postedDate":"March 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-27T12:29:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-27 12:29:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9185931","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9185931","identity":"rs-9185931","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}