Abdominal tuberculosis with pancreatic involvement: a case report

Infectious causes of acute pancreatitis: A systematic review

BACKGROUND

Infectious etiologies of acute pancreatitis (AP) are rare and include viruses, bacteria, mycobacteria, parasites, and fungi. We aimed to conduct a comprehensive review on infectious etiologies of AP analyzing the frequency, clinical features, and outcomes of individuals presenting with this condition.

METHODS

Eligible articles reporting on AP attributed to infectious etiologies were included. A comprehensive literature search of PubMed from time of inception and until September 6,2019 was performed using all relevant MeSH (medical subject heading) keywords. Articles were assessed for eligibility and independently reviewed by two reviewers for clinical features of AP, local complications, and mortality. Methodological quality of included studies was evaluated using the Murad tool.

RESULTS

A total of 212 articles were included, of which 168 (79.2%) were at high risk of bias. 320 cases of AP were identified. Viruses were the leading etiology of infection attributed AP (65.3%) followed by helminths (19.1%), and bacteria (12.5%). Protozoa, mycobacteria, and fungi accounted for the remaining 3.1% of cases. Mean age was 40.5 ± 18.4 years and M:F ratio was 1.94:1. Mortality occurred in 50 patients. Mortality rate was higher in the virus attributed AP patients than AP from other infectious etiologies (21.8% vs. 7.0%, p < 0.0005).

INTERPRETATION

Literature quality on infection attributed AP is limited. Virus attributed AP appears to carry a higher mortality than other etiologies of infection attributed AP.

Endoscopic ultrasound guided fine needle aspiration for diagnosis of pancreatic tuberculosis: Report of one case

The incidence of pancreatic tuberculosis is low. Pancreatic tuberculosis often presents as a pancreatic mass. If patients have no history of tuberculosis, pancreatic tuberculosis is often misdiagnosed as a pancreatic tumor. Only after surgery it can be diagnosed correctly. Endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) allows for biopsy of pancreatic tissue to conduct pathological examination, thus providing clinical evidence for the diagnosis of pancreas diseases. Compared with ultrasound and CT guided puncture, EUS-FNA has advantages of high accuracy and fewer complications.

Solitary pancreatic tuberculosis: A case report and literature review

AIM: To analyze the clinical characteristics of and diagnostic methods for solitary pancreatic tuberculosis.

METHODS: A case of solitary pancreatic tuberculosis was reported. In addition, 48 similar cases in published Chinese literature were identified to conduct a literature review. The data were identified by searching CNKI and CBM databases and browsing the relevant reference lists. The keywords were "pancreatic tuberculosis" and "tuberculosis and pancreas". The clinical manifestations were analyzed by descriptive methods. Criteria for the diagnosis of solitary pancreatic tuberculosis were: all lesions localized only in the pancreas and neighboring tissues, no other detectable foci of tuberculosis, no history of tuberculosis, having a clear chest radiograph, and a positive histological diagnosis.

RESULTS: Predominant symptoms consisted of abdominal pain (63.27%), weight loss (59.18%), fever (36.73%), jaundice (34.69%), and abdominal distention/bloating, without night sweats. Most patients were misdiagnosed with pancreatic tumors, and other misdiagnoses were pseudo-pancreatic cysts, chronic cholecystitis with pancreatitis, and cholecystic tumors. Erythrocyte sedimentation rate was elevated in 85.71% (12/14) of cases; PPD test was strongly positive in 55.56% (5/9); and CA19-9 was mildly elevated in 25% (2/8). CT scans showed a pancreatic mass (31/41) with heterogeneous hypodensity focus (9/41), calcification (6/41), or peripancreatic nodal enlargement (14/41). Ultrasound or CT-guided biopsies were performed in 8.16% (4/49) of cases, including one undergoing EUS-guided fine needle aspiration for cytologic diagnosis. Laparotomy was performed in 45 of 49 cases, and most received combined antituberculosis therapy. Anti-tuberculosis therapy was successful in 42 of 49 cases.

CONCLUSION: Solitary pancreatic tuberculosis is a rare condition with no specific clinical manifestations. The possibility of solitary pancreatic tuberculosis should be considered in patients presenting with a pancreatic mass and irregular pancreas enlargement. Diagnosis should be made cytologically, and laparotomy can be avoided if a definitive diagnosis was established before surgery. Solitary pancreatic tuberculosis can be effectively cured by antituberculosis therapy.

Tuberculous lymphadenitis as a cause of obstructive jaundice: A case report and literature review

Obstructive jaundice secondary to tuberculosis (TB) is extremely rare. It can be caused by TB enlargement of the head of the pancreas, TB lymphadenitis, TB stricture of the biliary tree, or a TB mass of the retroperitoneum. A 29-year-old man with no previous history of TB presented with abdominal pain, obstructive jaundice, malaise and weight loss. Ultrasonography (US), computer tomography (CT) scan and endoscopic retrograde cholangiopancreatography (ERCP) were suggestive of a stenosis of the distal common bile duct (CBD) caused by a mass in the posterior head of the pancreas. Tumor markers, CEA and CA19-9 were within normal limits. At operation, an enlarged, centrally caseous lymph node of the posterior head of the pancreas was found, causing inflammatory stenosis and a fistula with the distal CBD. The lymph node was removed and the bile duct resected and anastomosed with the Roux-en Y jejunal limb. Histology and PCR based-assay confirmed tuberculous lymphadenitis. After an uneventful postoperative recovery, the patient was treated with anti-tuberculous medication and remained well 2.5 years later. Though obstructive jaundice secondary to tuberculous lymphadenitis is rare, abdominal TB should be considered as a differential diagnosis in immunocompromised patients and in TB endemic areas. Any stenosis or fistulation into the CBD should also be taken into consideration, and biliary bypass surgery be performed to both relieve jaundice and prevent further stricture.

[The role of echoendoscopic biopsy in diagnosing tuberculosis of pancreas]

The diagnosis of an abdominal mass using imaging techniques is difficult for clinicians and radiologists. We report a case of an atypical peripancreatic mass, mimicking a carcinoma on abdominal computed tomography and which was only diagnosed after an echoendoscopic biopsy of the mass was performed. It is difficult to differentiate abdominal tuberculosis from a neoplasm, especially if there is no pulmonary tuberculosis. Usually, the diagnosis of abdominal tuberculosis is only confirmed histologically, after surgical resection of the mass. Echoendoscopic biopsy confirmed the infectious nature of the mass and prevented complicated and difficult surgery.

Peripancreatic tuberculosis mimicking pancreatic neoplasia

Tuberculosis of the pancreas and peripancreatic lymph nodes is an extremely rare disorder that has been reported with increased frequency in the past several years. Despite the fact that abdominal tuberculosis can generally be managed by pharmacotherapy alone, invasive procedures are often used before the establishment of the correct diagnosis, sometimes leading to unnecessary interventions and delayed treatment. To set the stage for our review, we first describe a case of a 31-year-old woman from India who initially presented with nonspecific symptoms and a pancreatic cystic lesion but was later diagnosed with peripancreatic tuberculosis. We then present a review of the current literature on peripancreatic and pancreatic tuberculosis, with a focus on diagnosis and management of the disease, but we also touch on issues such as epidemiology, infection control, and tissue acquisition. Finally, we offer clues that can be used to help identify patients who present with otherwise vague symptoms who may harbor pancreatic or peripancreatic tuberculosis. It is our hope that this case report and review of the literature will raise awareness and improve the management of this uncommon but serious disorder.