Tuberculous celiac axis lymphadenopathy mimicking cystic pancreatic neoplasm - a diagnostic dilemma

Coeliac lymph node abscess: A case report of a rare manifestation of extrapulmonary tuberculosis

Tuberculosis is a leading cause of death worldwide, especially in developing countries. It can affect any site in the body and have a myriad of presentations making diagnosis challenging. Tuberculous lymphadenitis in the abdomen is rare. We present a case of a 42-year-old man who presented with non-specific abdominal symptoms and was found to have an intraabdominal abscess on computed tomography scan of the abdomen. Endoscopic ultrasound-guided aspiration was performed, and tuberculosis was confirmed. This case highlights the importance of having a high clinical suspicion of tuberculosis even with vague symptoms in tuberculosis endemic countries. This would prevent unnecessary surgery as tuberculosis is responsive to anti-tuberculosis drugs.

Primary peripancreatic lymph node tuberculosis as a differential diagnosis of pancreatic neoplasia

Primary peripancreatic lymph node tuberculosis is an exceptional entity in immunocompetent patients, but its incidence is increasing in developed countries in recent years due to increasing immigration. It usually presents as a pancreatic mass and is misdiagnosed as pancreatic neoplasia in most cases, with the diagnosis of tuberculosis occurring after surgery. We report the case of a 38 year old Pakistani man with abdominal pain of several months duration, who was initially diagnosed with a pancreatic neoplasm after detecting a mass in the pancreatic isthmus by computed tomography (CT) and abdominal magnetic resonance imaging (MRI). However, after performing an endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB), the patient was diagnosed with peripancreatic lymph node tuberculosis. After receiving anti-tuberculous treatment, the patient presented clinical improvement, despite a small reduction in the lesion size. In conclusion, peripancreatic lymph node tuberculosis is part of the differential diagnosis of pancreatic neoplasia. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) represents a valuable and useful diagnostic tool for detecting this pathology, avoiding surgeries with a high morbidity and mortality.

Pancreatic tuberculosis

Pancreatic tuberculosis is very rare, but recently, there has been a spurt in the number of reports on pancreatic involvement by tuberculosis. It closely mimics pancreatic cancer, and before the advent of better imaging modalities it was often detected as a histological surprise in patients resected for a presumed pancreatic malignancy. The usual presentation involves abdominal pain, loss of appetite and weight, jaundice which can be associated with cholestasis, fever and night sweats, palpable abdominal lump, and peripheral lymphadenopathy. Computed tomography (CT) of the abdomen is an important tool for evaluation of patients with pancreatic tuberculosis. This CT imaging yields valuable information about the size and nature of tubercular lesions along with the presence of ascites and lymphadenopathy. However, there are no distinctive features on CT that distinguish it from pancreatic carcinoma. Endoscopic ultrasound provides high resolution images of the pancreatic lesions as well as an opportunity to sample these lesions for cytological confirmation. The presence of granulomas is the most common finding on histological/cytological examination with the presence of acid fast bacilli being observed only in minority of patients. As there are no randomized or comparative studies on treatment of pancreatic tuberculosis it is usually treated like other forms of tuberculosis. Excellent cure rates are reported with standard anti tubercular therapy given for 6-12 months.