Diagnosis and management of isolated pancreatic tuberculosis: recent experience and literature review

Peripancreatic tuberculosis

Peripancreatic tuberculosis (PTB) is a very rare variant of tuberculosis and its clinical and radiological findings are similar to those of pancreatic malignancy. Diagnosis of PTB is usually incidental and is made after surgical resection. We are presenting a male patient who had complaints of prolonged fever, significant weight loss and yellowish discolouration of eyes and dark-coloured urine. Investigations revealed that there was a pancreatic mass causing obstructive jaundice. However, the aetiology of the mass, whether tubercular or malignant, was not clear. Hence, the patient was planned for endoscopic ultrasound-guided fine needle aspiration cytology. Cytology and aspirate were sent for a cartridge-based nucleic acid amplification test which revealed the presence of Mycobacterium tuberculosis, sensitive to rifampicin. The patient improved completely after treatment with antitubercular therapy.

Misdiagnosis of pancreatic tuberculosis as a pancreatic cystic neoplasm - A case report

Pancreatic tuberculosis is an extremely rare condition. Its non-specific clinical and radiological findings resemble pancreatic malignancy. Here, we report a case of pancreatic tuberculosis that presented with abdominal pain and dyspeptic symptoms for 2 months and was misdiagnosed as a pancreatic cystic neoplasm. Abdominal magnetic resonance imaging showed a well-demarcated exophytic lesion with multiple T2 high signals small cystic areas in the anterior superior part of the head of the pancreas measuring 23 × 20 × 28 mm. This patient has undergone laparotomy and excision of the pancreatic mass. Histological examination revealed granulomatous inflammation of a lymph node with caseation, which was pathognomonic of tuberculosis. She was treated for tuberculosis for 6 months and has become symptom free. The diagnosis of pancreatic tuberculosis could be misleading and should be considered when dealing with pancreatic masses in countries with high incidence.

Exceptional association of hepatic and pancreatic tuberculosis mimicking metastatic pancreatic neoplasia: A case report and review of the literature

Introduction

Despite the high prevalence of tuberculosis in the world and especially in endemic areas such as Morocco, isolated hepatic and pancreatic tuberculosis and pancreatic tuberculosis remain rare and pose a real diagnostic problem.

Case presentation

We report a case illustrating an exceptional association of pancreatic tuberculosis with hepatic tuberculosis in a 44-year-old immunocompetent woman, in whom the presence of a pancreatic mass on imaging suggested a neoplastic origin. The diagnosis was rectified after bacteriological and pathological study of the CT-guided percutaneous biopsy specimens.

Discussion

The symptomatology of pancreatic and hepatic tuberculosis is unspecific and polymorphic and can mimic any intra-abdominal pathology. Abdominal ultrasound is often the first imaging modality used. The diagnosis of certainty is bacteriological.The treatment of pancreatic and hepatic tuberculosis is identical to the other extrapulmonary tuberculosis. the anti-bacillary drugs are the gold standard. Surgery is reserved for complicated forms.

Conclusion

The diagnosis of hepatic and pancreatic tuberculosis is a challenge for the clinician. The treatment is usually medical and based on antituberculosis treatment; surgery may be necessary in case of complications.

Pancreatic cyst-solid mass: tuberculosis

Question: A 29-year-old Chinese male was admitted to our department with a history of right upper quadrant pain for two months, anorexia, weight loss about 5 kg and without fever. The pain radiated to the back and it got worst lately. He didn’t have a history of tuberculosis. The sclera was mild icteric. Laboratory test results showed total bilirubin level increased to 58 umol/L (normal level <28 umol/L) and tumor markers were normal. Chest X-ray was normal. Abdominal contrastenhanced CT showed a 25 x 30 mm cyst-solid mass in the head of pancreas (Figure1. A) and the lesion was mild enhancement in arterial phase. Pancreatic tumor was considered. Endoscopic ultrasonography confirmed the mass with uneven echo in the pancreatic head and the boundary of the mass was not clear (Figure1. B). The lesion may invade the portal vein. As the patient was young and the operation was very traumatic, the patient refused surgery unless the lesion was proved to be a tumor.

Isolated pancreatic tuberculosis with elevated CA 19-9 levels masquerading as a malignancy: A rare case report and literature review

RATIONALE

Primary pancreatic tuberculosis is extremely rare, it presents with non-specific clinical symptoms and imaging features; it may be falsely identified as a malignancy of the pancreas.

PATIENT CONCERNS

A 41-year-old male with no history of tuberculosis presented to our hospital with a 2-week history of jaundice.

DIAGNOSES

Abdominal computed tomography (CT) showed a heterogeneous irregular hypodense mass in the head of the pancreas causing dilatation of the common bile duct (CBD), and it was enhanced after infusion of contrast material. Serum cancer antigen (CA) 19-9 was 124 U/mL (normal: 0-40 U/mL). He was preoperatively diagnosed as having a pancreatic carcinoma.

INTERVENTIONS

A Whipple procedure (pancreaticoduodenectomy) was performed. The pancreatic tuberculosis was confirmed based on the postoperative histopathologic specimens and acid-fast stain of the drainage. Then isoniazid, rifampicin, and ethambutol were given for 6 months.

OUTCOMES

The patient recovered very well. There was no evidence of tuberculosis recurrence, and the patient remained free of symptoms during the follow-up examination 1 year after surgery.

LESSONS

Pancreatic tuberculosis should be considered when the mass is located on the head of the pancreas even with elevated serum CA19-9 levels.

Pediatric Pancreatic Tuberculosis: A Case Report and Review of the Literature

Pancreatic tuberculosis (TB) is an uncommon form of extrapulmonary TB and represents a diagnostic challenge for physicians. Pancreatic TB presents with nonspecific signs and symptoms and may mimic malignancy. However, pancreatic TB rarely occurs in children. Here, we present a case of a 5-year-old girl with pancreatic TB and markedly elevated serum cancer antigen- (CA-) 125 levels, thus raising the suspicion of malignancy, but positivity for Mycobacterium tuberculosis DNA was noted. The patient recovered after being administered standard antitubercular therapy for one year. This case suggests that clinicians should have a heightened suspicion of pancreatic TB when faced with pancreatic lesions despite the fact that increased CA-125 may indicate malignancy. Laparoscopy combined with peritoneal biopsy and polymerase chain reaction (PCR) may provide a new method to confirm the diagnosis.

Tuberculosis of the Liver, Biliary Tract, and Pancreas

Tuberculosis of the liver, biliary tract, and pancreas is discussed. In addition, tuberculosis in the setting of HIV-AIDS and liver transplantation is explored. Drug-induced liver injury secondary to antituberculosis medication and monitoring and prophylactic treatment for such injury is also considered.

A Rare Case of Isolated Pancreatic Tuberculosis

Pancreatic tuberculosis (TB) is a rare but important entity to consider when evaluating a pancreatic mass, especially in patients from endemic areas. Its clinical and radiologic features may mimic those of a pancreatic neoplasm, making it a difficult clinical diagnosis. We present a case of a 31-year-old Indian man who presented with fevers, night sweats, weight loss, and epigastric pain. Abdominal magnetic resonance imaging (MRI) showed a pancreatic head mass. Biopsy of the mass was consistent with pancreatic tuberculosis.

Pancreatic Tuberculosis

Tuberculosis of the pancreas is extremely rare and in most of the cases mimics pancreatic carcinoma. There are a number of case reports on pancreatic tuberculosis with various different presentations, but only a few case series have been published, and most of our knowledge about this disease comes from individual case reports. Patients of pancreatic tuberculosis may remain asymptomatic initially and manifest as an abscess or a mass involving local lymph nodes and usually present with non-specific features. Pancreatic tuberculosis may present with a wide range of imaging findings. It is difficult to diagnose tuberculosis of pancreas on imaging studies as they may present with masses, cystic lesions or abscesses and mass lesions in most of the cases mimic pancreatic carcinoma. As it is a rare entity, it cannot be recommended but suggested that pancreatic tuberculosis should be considered in cases with a large space occupying lesions associated with necrotic peripancreatic lymph nodes and constitutional symptoms. Ultrasonography/computed tomography/endosonography-guided biopsy is the recommended diagnostic technique. Most patients achieve complete cure with standard antituberculous therapy. The aims of this study are to review clinical presentation, diagnostic studies, and management of pancreatic tuberculosis and to present our experience of 5 cases of pancreatic tuberculosis.

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

Cystic pancreatic neoplasms are tumors with malignant potential treated surgically. Isolated tuberculosis of celiac lymph nodes is rare, treatment of this entity being non-surgical. Radiological appearances of cystic pancreatic neoplasm and tuberculous peripancreatic lymph nodal mass is similar and difficult to differentiate. Here we present a case of mass lesion in the region of pancreatic head mimicking cystic pancreatic neoplasm which was actually abdominal tuberculous lymphadenopathy proven by biopsy.

Pancreatic tuberculosis or autoimmune pancreatitis

Introduction. Isolated pancreatic and peripancreatic tuberculosis is a challenging diagnosis due to its rarity and variable presentation. Pancreatic tuberculosis can mimic pancreatic carcinoma. Similarly, autoimmune pancreatitis can appear as a focal lesion resembling pancreatic malignancy. Endoscopic ultrasound-guided fine needle aspiration provides an effective tool for differentiating between benign and malignant pancreatic lesions. The immune processes involved in immunoglobulin G4 related systemic diseases and tuberculosis appear to have some similarities. Case Report. We report a case of a 59-year-old Southeast Asian male who presented with fever, weight loss, and obstructive jaundice. CT scan revealed pancreatic mass and enlarged peripancreatic lymph nodes. Endoscopic ultrasound-guided fine needle aspiration confirmed the presence of mycobacterium tuberculosis. Patient also had high immunoglobulin G4 levels suggestive of autoimmune pancreatitis. He was started on antituberculosis medications and steroids. Clinically, he responded to treatment. Follow-up imaging showed findings suggestive of chronic pancreatitis. Discussion. Pancreatic tuberculosis and autoimmune pancreatitis can mimic pancreatic malignancy. Accurate diagnosis is imperative as unnecessary surgical intervention can be avoided. Endoscopic ultrasound-guided fine needle aspiration seems to be the diagnostic test of choice for pancreatic masses. Long-term follow-up is warranted in cases of chronic pancreatitis.

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.

Pancreatic Tuberculosis Diagnosed with Endoscopic Ultrasound–Guided Fine Needle Aspiration

Pancreatic tuberculosis is very rare, especially in immunocompetent patients, and represents a diagnostic challenge. The clinical features in patients with pancreatic tuberculosis are usually nonspecific, and the radiologic features may mimic pancreatic malignancy or pancreatitis. We describe four cases with pancreatic tuberculosis mimicking carcinoma or pancreatic cyst on imaging. None of these patients was immunocompromised. Endoscopic ultrasound–guided fine needle aspiration demonstrated necrotizing granulomatous inflammation in these cases and acid-fast bacilli in two of them. We suggest that pancreatic tuberculosis should be included in the differential diagnosis of a pancreatic cystic or solid-cystic mass, especially in patients from a region where tuberculosis is endemic.

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.

Imaging of miscellaneous pancreatic pathology (trauma, transplant, infections, and deposition)

In this article's coverage of miscellaneous pancreatic topics, a brief review of pancreatic trauma; pancreatic transplantation; rare infections, such as tuberculosis; deposition disorders, including fatty replacement and hemochromatosis; cystic fibrosis; and others are discussed with pertinent case examples.

Distinctive endoscopic ultrasound features of isolated pancreatic tuberculosis and requirements for biliary stenting

BACKGROUND & AIMS

There are insufficient data about the appearance of isolated pancreatic tuberculosis on endoscopic ultrasound (EUS). The safety and efficacy of antitubercular therapy (ATT) in patients with pancreatic tuberculosis with cholestasis are also relatively unknown.

METHODS

We evaluated 6 patients with isolated pancreatic head tuberculosis retrospectively and compared their EUS findings with those of 25 patients with pancreatic head adenocarcinoma.

RESULTS

There was no difference in the EUS appearance between the 2 diseases. The mean diameter of the common bile duct was significantly greater in patients with pancreatic adenocarcinoma. The pancreatic duct was dilated in 20 of 25 patients with pancreatic adenocarcinoma (80%), whereas it was dilated in only 1 of 6 patients with pancreatic tuberculosis (16.6%) (P < .05). All 6 patients with pancreatic tuberculosis had a resolution of their cholestatic symptoms within 4 weeks of starting ATT alone. None of these patients required biliary stenting.

CONCLUSIONS

None of the EUS features of a mass lesion caused by pancreatic tuberculosis are distinctive. Once diagnosed, these patients can be successfully treated with ATT without needing biliary stenting.

Coexistence of pancreatic tuberculosis with systemic brucellosis: a case report

Isolated pancreatic tuberculosis is an extremely rare clinical entity and is difficult to diagnose particularly in immunocompetent individuals. Clinical findings and symptomatology of brucellosis are often similar to tuberculosis thus making the differentiation amongst the two entities difficult. We report a case of pancreatic tuberculosis with systemic brucellosis in a 29 year old veterinarian who presented with epigastric pain and loss of appetite. Initial investigations revealed leukocytosis with moderately elevated transaminase, gamma glutamyl transferase, amylase and lipase levels. Imaging studies revealed an anechoic multiloculated cyst in the body and tail of the pancreas. Given the patient’s occupational risk coupled with the presence of a positive Brucella agglutination test (with a titer of 1:320); a diagnosis of pancreatitis secondary to brucellosis was given. In addition to standard pancreatitis therapy of bowel rest with intravenous fluid/electrolyte replacement, anti-brucellosis therapy was also administered. The patient’s initial response to therapy was positive however, 6 weeks into therapy, his abdominal pain recurred and repeat CT scan revealed the development of a pseudocyst in the pancreas. After failing a second attempt at conservative supportive therapy, the patient underwent an explorative laparotomy. Histological examination of the resected pancreatic specimen showed necrosis and was positive for tuberculosis by polymerase chain reaction. Herein, we describe the first case reported in the medical literature of the coexistence of systemic brucellosis with pancreatic tuberculosis. We suggest that the possibility of the coexistence of brucellosis with tuberculosis be kept in mind when assessing pancreatitis patients in endemic regions and in individuals with occupational risk hazards.

Pancreatic tuberculosis presenting with pancreatic cystic tumor: a case report and review of the literature

Pancreatic tuberculosis is a rare clinical entity, presenting as malignancy mimicking pancreatic mass. Therefore, it represents a diagnostic challenge. To date, ten cases have been reported in Korea. I report an additional case and review all Korean reports about pancreatic tuberculosis. A 57-year-old woman presented with abdominal pain. Abdominal computed tomography (CT) revealed a 2.2x1.2 cm cystic mass in pancreatic body. She was followed for nine months, at which time a cystic mass was enlarged to 3.3x2.2 cm in size on the CT. An exploratory laparotomy was performed for the accurate diagnosis and to rule out the possibility of malignant change. Pathological examination of the resected specimen revealed chronic granulomatous inflammation with caseous necrosis and multinucleated giant cells, which was compatible with tuberculosis. Among the 11 cases of pancreatic tuberculosis, five cases were combined with pulmonary tuberculosis. The pancreatic tuberculosis frequently presented with multicystic pancreatic mass (81%) and the most common anatomic locations were the head (73%), tail (18%), and body (9%). Three cases were diagnosed by using US or EUS guided fine needle aspiration biopsy (FNAB), and all cases were medically cured without exploratory laparotomy. In summary, pancreatic tuberculosis, despite its rarity, should be considered for differential diagnosis of pancreatic cystic mass in endemic countries. Clinical suspicion and accurate diagnostic approach including FNAB of pancreatic tuberculosis are needed to avoid performing unnecessary laparotomy.

Yield of EUS-guided FNA on the diagnosis of pancreatic/peripancreatic tuberculosis

BACKGROUND

Pancreatic/peripancreatic tuberculosis (TB) is a very rare clinical entity, even in countries with high incidences of TB. The diagnosis of pancreatic/peripancreatic TB with EUS-guided FNA (EUS-FNA) remains a diagnostic challenge because of limitations of the endoscopists' expertise on this condition.

OBJECTIVE

This study evaluated the yield and usefulness of EUS-FNA in patients with pancreatic/peripancreatic TB.

DESIGN

A retrospective analysis was performed.

SETTING

A tertiary teaching hospital in Seoul, Korea.

PATIENTS

Baseline demographic and clinical features were evaluated in 21 consecutive patients with pancreatic/peripancreatic TB who underwent EUS-FNA between September 2003 and April 2007.

RESULTS

The mean lesion diameter was 31.3 +/- 14.6 mm. Thirteen patients (61.9%) showed granulomatous inflammation on histopathologic examination, and 10 of 15 patients (66.7%) were positive on a TB polymerase chain reaction assay. Ziehl-Neelsen staining was positive in 4 of 15 patients (26.7%), and 3 of 8 patients (37.5%) had cultures positive for Mycobacterium tuberculosis. EUS-FNA correctly diagnosed pancreatic/peripancreatic TB in 16 patients (76.2%). Therefore, unnecessary surgery was avoided for these patients.

LIMITATION

A retrospective study.

CONCLUSIONS

EUS-FNA is a safe and promising method for the diagnosis of pancreatic/peripancreatic TB. Use of this method may help us to avoid the use of surgery and provide timely and accurate diagnosis.

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.

Disseminated disease severity as a measure of virulence of Mycobacterium tuberculosis in the guinea pig model

Virulence is the measure of pathogenicity of a microorganism as determined by its ability to invade host tissues and to produce severe disease. In the low-dose aerosol guinea pig model the virulence of multiple strains of Mycobacterium tuberculosis was determined by measuring time of survival, bacterial loads in target organs, and the severity of pulmonary and extra-pulmonary lesions. Erdman K01, CSU93/CDC1551 and HN878 had shorter survival times compared to the common laboratory strain H37Rv. After 30 days of the infection bacilli had disseminated from the lungs resulting in microscopically visible lesions in peribronchial lymph nodes, peripancreatic lymph nodes, spleen, liver, pancreas, adrenal and heart. The extent of the lesion necrosis paralleled virulence when survival times were used as a measure as Erdman K01 and the two clinical isolates caused more necrosis and resulted in sooner death in infected animals than the H37Rv. The extent of extra-pulmonary lesion necrosis was a better predictor of virulence than the number of viable bacilli in the tissue. Overall, this study emphasizes the point that extra-pulmonary disease is a prominent feature of the guinea pig model and dissemination to organs not normally assayed such as the heart and adrenal glands should be taken into account in the assessment of the disease process.

Pancreatic tuberculosis in a human immunodeficiency virus positive patient: A case report

Despite the increased incidence of tuberculosis related to human immunodeficiency virus (HIV) in recent decades, pancreatic tuberculosis has rarely been described. We report a case of pancreatic tuberculosis in a 39-year-old African man who presented with progressive dysphagia, vomiting, weight loss and productive cough, accompanied by localized epigastric pain and one episode of melena. HIV-1 testing was positive and lymphocyte subset profile showed CD₄ count of 9/mm³. Abdominal computed tomography (CT) scan with contrast revealed a cystic mass in the body of the pancreas, significant portal and retroperitoneal cystic adenopathy, and multiple cystic lesions in the spleen and liver. CT guided cyst aspiration and node biopsy detected Mycobacterium tuberculosis. The patient responded well on antituberculosis and antiretroviral therapy. Tuberculosis rarely involves the pancreas, probably due to the presence of pancreatic enzymes which interfere with the seeding of Mycobacterium tuberculosis. Pancreatic tuberculosis is considered to be the result of dissemination of the infection from nearby lymphatic nodes. Endoscopic ultrasound or CT guided fine needle aspiration for cytology is the recommended diagnostic technique. Although the prognosis is good with anti-tuberculosis treatment, it could be fatal without correct diagnosis and treatment. The clinician’s high index of suspicion of pancreatic tuberculosis and application of FNAB to obtain pathological evidence are extremely important to a correct diagnosis, especially in young HIV positive patients.

Pancreatic tuberculosis with a pancreaticobiliary fistula

Pancreatic tuberculosis (TB) is a rare condition that is sometimes difficult to differentiate from pancreatic cancer or other malignancies. A 75-year-old man was admitted to our hospital because of weight loss, fever, and diarrhea. Abdominal ultrasonography and computed tomography (CT) revealed a 3-cm mass in the pancreas head with abdominal lymphadenopathy. Endoscopic retrograde cholangiopancreatography did not show pancreatic duct stenosis or dilatation, but a pancreaticobiliary fistula was demonstrated. Cytological and bacteriological examinations of the pancreatic juice and bile were negative. Endoscopic ultrasonography-guided fine needle aspiration of the mass was not diagnostic. Colonoscopic features and biopsy specimens affirmed the diagnosis of TB, and treatment with antitubercular drugs was started. The pancreatic mass disappeared within 8 weeks and the pancreaticobiliary fistula resolved.

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of peripancreatic tuberculous lymphadenitis

The percentage of patients with atypical extrapulmonary forms of tuberculosis has been increasing. Among extrapulmonary tuberculosis cases, tuberculosis of the pancreas and peripancreatic lymph nodes is a rare clinical entity. Here, we present a case of peripancreatic tuberculous lymphadenitis diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) both cytologically and microbiologically. A 23-year-old man had a 1-week history of epigastralgia and low-grade fever. Subsequently, he was found to have an abnormality on abdominal ultrasound. A computed tomography scan of the abdomen showed a solitary mass consisting of multiple cystic components with rim enhancement in the peripancreatic portion contiguous to the gall bladder. Endoscopic ultrasound-guided fine-needle aspiration was performed to confirm the diagnosis. The cytological examination revealed epithelioid cells with caseous necrosis, indicating tuberculosis. The aspirated fluid was positive by polymerase chain reaction (PCR) analysis and culture for Mycobacterium tuberculosis. Antituberculosis therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide was started based on the PCR and cytology results, and a good response to the treatment was noted. Endoscopic ultrasound-guided fine-needle aspiration cytology with PCR analysis is very useful for the diagnosis of peripancreatic tuberculosis.

Review of endoscopic ultrasound-guided fine-needle aspiration cytology

This review, based on the Hennepin County Medical Center experience and review of the literature, vastly covers the up-to-date role of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) in evaluating tumorous lesions of the gastrointestinal tract and adjacent organs. Emphasis is given to the tumoral and nodal staging of esophageal, pulmonary, and pancreatic cancer. This review also discusses technical, pathological, and gastroenterologic aspects and the role of the pathologist and endosonographer in the evaluation of these lesions, as well as the corresponding FNA cytology and differential diagnosis.

Diabetes mellitus, tuberculosis and the mycobacteria: two millenia of enigma

The thought that tuberculosis and the mycobacteria could cause diabetes seems farfetched, but is not. The peculiar relationship and frequent association of diabetes mellitus and tuberculosis has been observed for more than 2000 years, yet the reason for this correlation is, to this day, not known. Before the discovery of insulin, a diagnosis of diabetes was a death sentence within 5 years, and the usual cause of that death was tuberculosis. Despite this, in the 5th century, tuberculosis was already being portrayed as a "complication" of diabetes, a view little changed to this day, parroting Root's original 1934 description of "a one-sided relationship": tuberculosis still seen as a common complication of diabetes, while diabetes is thought to be no more common among TB patients than in the population at large. To Nichol's, this was "not logically tenable" and in his study of 178 otherwise healthy, non-diabetic military men with tuberculosis at Fitzsimmons Army Hospital, one-third had abnormal glucose screening tests. But despite his findings and those of Reaud in New York and others, this was not being recognized elsewhere, and Nichols wanted to know why. Nichols concluded that the incidence of diabetes among tuberculosis patients was considerably underestimated and that in tuberculosis patients, diabetes develops quite commonly. Diabetes was easy to detect. Tuberculosis and the mycobacteria were not. The evidence for a mycobacterial cause of diabetes is mounting rapidly. Schwartz and Haas both linked Type-2 diabetes to tuberculosis. And the pancreatic islet amyloid deposits that they found as a by-product of systemic tubercular infection have recently been dissolved by rifampicin, a first line drug against tuberculosis. Engelbach spoke of "transitory" diabetes in TB and Karachunskii noted changes in carbohydrate metabolism in patients with tuberculosis which commonly led to insulin deficiency with persistent hyperglycemia. Furthermore, mycobacterial elements have been shown recently not only to cause "autoimmune" Type-1 diabetes in NOD (non-obese diabetic) mice, but act as a vaccine to stop the inevitable diabetes that would otherwise materialize. The documentation of patient cases where TB has preceded and come before the development of diabetes is extensive yet underplayed and both Lin's and Tsai's studies speak of tuberculosis complicated by diabetes. Diabetes has been around since the first century AD, in a perpetual state of coping and managing. It is time, it is long past time, to cure diabetes. But current models as to its cause are not equipping us to do so.