Pancreatic mass caused by Mycobacterium tuberculosis with reduced drug sensitivity

Pancreatic and peripancreatic tuberculosis presenting as hypoechoic mass and malignancy diagnosed by ultrasound-guided fine-needle aspiration cytology

Background:

Pancreatic and peripancreatic tuberculosis is an extremely uncommon disease, presenting as hypoechoic mass on ultrasonography and imaging mimicking malignancy. Consequently, it represents a diagnostic challenge.

Aims:

To study 14 unusual cases of pancreatic and peripancreatic tuberculosis undergoing ultrasound-/endoscopic-guided fine-needle aspiration cytology (FNAC) in the 5-year period from 2006 to 2010.

Materials and Methods:

Endoscopic-guided FNAC was done in two cases, while ultrasound-guided FNAC was performed in 12 cases using 22-G needles via a percutaneous transabdominal approach. The aspirated material was quickly smeared onto glass slides, air dried, and wet fixed in 95% ethyl alcohol for subsequent Papanicolaou staining.

Results:

All pancreatic and peripancreatic tuberculosis cases showed solid-cystic pancreatic mass. Smears showed epithelioid cell granulomas, multinucleated giant cells, mixed inflammatory cells and histiocytes against a necrotic background. The common anatomic locations were the head, peripancreatic, tail and body of the pancreas.

Conclusions:

Ultrasound-/endoscopic-guided FNAC is a safe, reliable and cost-effective method for preoperative diagnosis of pancreatic and peripancreatic tuberculosis. Clinical symptoms and accurate diagnostic approach by ultrasound-/endoscopic-guided FNAC of pancreatic and peripancreatic tuberculosis is needed to avoid performing redundant laparotomy. Despite its rarity, pancreatic and peripancreatic tuberculosis should be considered for differential diagnosis of pancreatic and peripancreatic cystic mass in endemic developing countries.

Management of multidrug-resistant tuberculosis: Update 2007

Multidrug-resistant tuberculosis (MDR-TB) with bacillary resistance to at least isoniazid and rifampicin in vitro is a worldwide phenomenon. Hot spots of the disease are found scattered in different continents. Prevention of its development through good tuberculosis control programmes operating under the directly observed therapy, short-course (DOTS) strategy is of paramount importance. However, with established MDR-TB, treatment with alternative and specific chemotherapy is necessary to achieve a beneficial outcome. Such an approach on a programme basis is currently known as the 'DOTS-Plus' strategy. Second-line (reserve) drugs utilized in the treatment of MDR-TB are generally less potent and more toxic, perhaps with the notable exceptions of some fluoroquinolones and injectable agents. Surgery has a distinct adjunctive role for the management of MDR-TB in selected patients. The emergence of extensively drug-resistant tuberculosis (XDR-TB), that is, MDR-TB with additional bacillary resistance to the fluoroquinolones and injectables, has provided a very alarming challenge to global health, as the disease currently has a low cure rate and high mortality. In order to combat XDR-TB, strengthening of DOTS and DOTS-Plus programmes is mandatory, especially in the face of surging HIV infection. Furthermore, more attention needs to be focused on developing new drugs with potent bactericidal and sterilizing activities and low side-effects, and above all, drugs that are affordable for communities worldwide.

Tuberculosis of pancreas and peripancreatic lymph nodes in immunocompetent patients: experience from China

AIM: To determine the clinical, radiographic and laboratory characteristics, diagnostic methods, and therapeutic variables in immunocompetent patients with tuberculosis (TB) of the pancreas and peripancreatic lymph nodes.

METHODS: The records of 16 patients (6 male, 10 female; mean age 37 years, range 18-56years) with tuberculosis of the pancreas and peripancreatic lymph nodes from 1983 to 2001 in the Southwest Hospital were analyzed retrospectively. In addition, 58 similar cases published in Chinese literature were reviewed and summarized. We reviewed the clinical, radiographic and laboratory findings, diagnostic methods, therapeutic approaches, and outcome in the patients. Criteria for the diagnosis of pancreatic tuberculosis were the presence of granuloma in histological sections or the presence of Mycobacterium tuberculosis DNA by polymerase chain reaction (PCR).

RESULTS: Predominant symptoms consisted of abdominal nodule and pain (75%), anorexia/weight loss (69%), malaise/weakness (64%), fever and night sweats (50%), back pain (38%) and jaundice (31%). Swelling of the head of the pancreas with heterogeneous attenuation echo was detected with ultrasound in 75% (12/16). CT scan showed pancreatic mass with heterogeneous hypodensity focus in all patients, with calcification in 56% (9/16) patients, and peripancreatic nodules in 38% (6/16) patients. Anemia and lymphocytopenia were seen in 50% (8/16) patients, and pancytopenia occurred in 13% (2/16) patients. Hypertransaminasemia, elevated alkaline phosphatase (AP) and GGT were seen in 56% (9/16) patients. The erythrocyte sedimentation rate (ESR) was elevated in 69% (11/16) cases. Granulomas were found in 75% (12/16) cases, and in 38% (6/16) cases caseous necrosis tissue was found. Laparotomy was performed in 75% (12/16) cases, and ultrasound-guided fine needle aspiration (FNA) was done in 63% (10 of 16). The most commonly used combinations of medications were isoniazid/rifampin/streptomycin (63%, n = 10) and isoniazid/rifampin pyrazinamide/streptomycin or ethambutol (38%, n = 6). The duration of treatment lasted for half or one year and treatment was successful in all cases. The characteristics of 58 cases from Chinese literature were also summarized.

CONCLUSION: Tuberculosis of the pancreas and peripancreatic lymph nodes should be considered as a diagnostic possibility in patients presenting with a pancreatic mass, and diagnosis without laparotomy is possible if only doctors are aware of its clinical features and investigate it with appropriate modalities. Pancreatic tuberculosis can be effectively cured by antituberculous drugs.