Education and imaging. Gastrointestinal: pancreatic tuberculosis masquerading as malignancy

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.

Calcified peripancreatic lymph nodes in pancreatic and hepatic tuberculosis mimicking pancreatic malignancy: A case report and review of literature

RATIONALE

Tuberculosis remains a serious menace to the health of people. Isolated hepatic tuberculosis is rare and pancreatic tuberculosis is extremely rare. The preoperative diagnosis of pancreatic tuberculosis remains a great challenge.

PATIENT CONCERNS

A 58-year-old Asian woman was referred to our hospital for evaluation of low back pain for 4 years and abdominal pain for 1 month.

DIAGNOSES

Computed tomography (CT) of the abdomen showed a hypodense mass in the pancreatic head and neck with abundant calcifications, a hypodense lesion in the liver without calcification, peripancreatic lymphadenopathy, calcifications in some lymph nodes. CT-guided fine needle aspiration biopsy of the hepatic lesion was carried out and the cytological examination revealed hepatic tuberculosis.

INTERVENTIONS

The patient was treated with antituberculous therapy for 1 year.

OUTCOMES

Low back pain and abdominal pain disappeared 3 months after initial treatment and after 2 year of follow-up, the patient was asymptomatic.

LESSONS

Our data hint that calcifications in both pancreatic lesions and peripancreatic lymph nodes may suggest pancreatic tuberculosis rather than pancreatic malignancy.

Ultrasound imaging features of isolated pancreatic tuberculosis

BACKGROUND AND OBJECTIVES

Isolated pancreatic tuberculosis (PTB) is extremely rare worldwide. The purpose of this multicenter retrospective study is to analyze imaging features of histologically confirmed isolated PTB in order to determine the diagnostic features of the new methods contrast enhanced ultrasound (CEUS), ultrasound elastography and contrast enhanced endoscopic ultrasound (CE-EUS).

PATIENTS AND METHODS:

We report on a retrospective data collection of 12 cases of PTB confirmed by histology or cytology. All examinations were interpreted by two independent readers in consensus. CEUS, CE-EUS and ultrasound elastography were performed according to the European Federation of Societies for Ultrasound in Medicine and Biology guidelines.

RESULTS:

In PTB patients the common bile duct was never dilated. Multiple retroperitoneal lymph nodes are the second important B-mode ultrasound feature detected in 75% of PTB patients. CE-EUS was performed in three PTB patients demonstrating hyperenhancement. On elastography, all PTB lesions were markedly stiffer than surrounding pancreatic parenchyma.

CONCLUSIONS:

Here we report the first time on CEUS and elastography features of PTB. PTB had some typical imaging features with iso- or hyperenhancement on CE(E) US. PTB is markedly stiffer on elastography. If clinicians are aware of clinical features of PTB and conduct appropriate investigations with multiple modalities including B-mode ultrasound, CEUS, and EUS guided fine needle aspiration, diagnosis of PTB without laparotomy is possible and the disease can be effectively treated with anti-tuberculous drugs.