Tuberculosis of the pancreas presenting as metastatic pancreatic carcinoma. A case report and review of the literature

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.

Primary pancreatic tuberculosis mimicking pancreatic body cancer. A case report and review of the literature

Isolated pancreatic tuberculosis (PT) is an extremely rare disease, with non-specific clinical characteristics, making the diagnosis often challenging with pancreatic cancers.

Here we report a case of a 36-year-old female, who was admitted to our hospital after suffering from a 3-month history of epigastric abdominal pain, night sweats and weight loss. The physical examination was normal. The radiological findings revealed the presence of a pancreatic mass and multiple abdominal lymphadenopathy, suggestive of malignancy. The initial differential diagnosis suspected was pancreatic tuberculosis. Tuberculosis skin test was performed and was highly positive (>22 mm). Computed tomography (CT)-guided biopsy of peripancreatic lymph node was carried out and the histopathological exam confirmed the diagnosis of PT. Therefore, anti-tuberculous therapy was initiated, leading to clinical and radiological improvement.

The diagnosis of PT is rare and can sometimes be misleading. It should be considered when a pancreatic mass is observed, especially in endemic countries, to ovoid unnecessary interventions.

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Isolated pancreatic tuberculosis is an extremely rare disease, with non-specific clinical characteristics.

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Clinical presentation and radiological findings of a pancreatic mass may be suggestive of malignancy.

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Preoperative microbiological or/and histological diagnosis should be made to avoid the patient unnecessary surgical procedures.

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.

Tuberculosis--the great mimicker

Tuberculosis is an immense health problem in the developing world, and it remains a health care challenge in the developed world. It can affect virtually any organ system in the body. Diagnosis of tuberculosis is often difficult. Many patients with tuberculosis present with nonspecific symptoms, negative purified protein derivative skin test result, and negative findings on culture specimens. Cross-sectional imaging with ultrasound, multidetector computed tomography, and magnetic resonance imaging plays an important role in the diagnosis of tuberculosis. Tuberculosis demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. Tuberculosis is a great mimicker as its radiologic manifestations can simulate numerous other diseases across the body systems. However, recognition and understanding of the common and uncommon radiologic manifestations of tuberculosis should alert considering tuberculosis in the high-risk population and correct clinical setting to enable appropriate treatment.

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.

Imaging of tuberculosis of the abdominal viscera: beyond the intestines

There is an increasing incidence of both intra- and extra-thoracic manifestations of tuberculosis, in part due to the AIDS epidemic. Isolated tubercular involvement of the solid abdominal viscera is relatively unusual. Cross-sectional imaging with ultrasound, multidetector computed tomography (CT), and magnetic resonance imaging (MRI) plays an important role in the diagnosis and post treatment follow-up of tuberculosis. Specific imaging features of tuberculosis are frequently related to caseous necrosis, which is the hallmark of this disease. However, depending on the type of solid organ involvement, tubercular lesions can mimic a variety of neoplastic and nonneoplastic conditions. Often, cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis, and image-guided tissue sampling is needed. In this article, we review the pathology and cross-sectional imaging features of tubercular involvement of solid abdominopelvic organs with a special emphasis on appropriate differential diagnoses.

Tuberculosis and malignancy

BACKGROUND

Tuberculosis (TB) and malignancy represent global threats claiming millions of lives and inflicting formidable suffering worldwide. Surprisingly, the pathophysiological and practical implications of their co-existence have received little attention.

METHODS

Therefore, we sought to review the available literature on the field and identify data regarding the association between TB and malignancy in order to highlight the neglected aspects of this association and probably derive clinically useful information. We searched PubMed up to June 2008 for case reports, case series, non-comparative and comparative studies that were written in English and reported data on the occurrence of both TB infection and a neoplastic disorder in the same patient(s). The development of mycobacterial infections in patients with immunocompromized conditions is well known and was considered outside the scope of this review.

EVIDENCE SYNTHESIS

The synthesis of the available evidence enabled us to establish three different types of association between malignancy and TB: (i) the development of cancer on the background of a previous tuberculous infection; (ii) the concurrent existence of TB and malignancy in the same patient(s) or clinical specimen(s); and (iii) the diagnostic challenges arising from the multi-faceted presentations of these two disorders.

CONCLUSION

We conclude that clinicians need to be aware of the protean manifestations of TB and cancer and maintain a high index of suspicion for simultaneous and/or misleading presentations. In addition, further research is required to determine if a tuberculous infection, being similar to other chronic infections and inflammatory conditions, may facilitate carcinogenesis.

Pancreatic tuberculosis masquerading as pancreatic serous cystadenoma

Solitary pancreatic involvement of tuberculosis is rare, especially in an immunocompetent individual, and it may be misdiagnosed as pancreatic cystic neoplasms. Pancreatic cystic neoplasms are being identified in increasing numbers, probably because of the frequent use of radiology and advances in endoscopic techniques. However, they are composed of a variety of neoplasms with a wide range of malignant potential, and it is often difficult to differentiate pancreatic tuberculosis mimicking cystic neoplasms from benign or malignant pancreatic cystic neoplasms. Non-surgical diagnosis of pancreatic tuberculosis is inconclusive and continues to be a challenge in many cases. If so, then laparotomy should be employed to establish the diagnosis. Therefore, pancreatic tuberculosis should be kept in mind during the differential diagnosis of solitary cystic masses in the pancreas. We report a patient who had solitary pancreatic tuberculosis masquerading as pancreatic serous cystadenoma.

[Pancreatic tuberculosis with duodenal fistula]

Tuberculosis is a common infection worldwide. In developed countries, the incidence of this disease was low until a few years ago. However, due to the rise in immigration and HIV infection, the frequency of tuberculosis has recently shown a marked increase. Although the most frequent location of tuberculosis infection continues to be respiratory, infection in other sites, such as musculoskeletal, genitourinary, neurological and abdominal areas, has recently become more common. Abdominal infection, the most frequently described extrapulmonary localization, commonly affects the spleen, liver, ileocecal region, peritoneum, and regional lymph nodes. Tuberculosis of the pancreas is considered a rare entity.

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.

Pancreatic tuberculosis-abdominal tuberculosis presenting as pancreatic abscesses and colonic perforation

Isolated pancreatic tuberculosis is an extremely rare condition, more so in an immunocompetent individual. Its presentation as pancreatic abscesses with colonic perforation has not been reported so far. This condition poses difficulties in clinical diagnoses. Herein we report a case who was operated in another hospital for pancreatic abscesses, and referred to our institution later when he developed fecal peritonitis due to colonic perforation. Re-laparotomy, resection and exteriorisation of the colon were done. Acid fast bacilli was seen in the histopathological examination of the resected colon. The patient responded remarkably to anti-tuberculous therapy and two sittings of debridement. Post procedure the patient developed pancreatic fistula, which was managed successfully with stenting. Pancreatic tuberculosis should be considered as a differential diagnosis when pancreatitis is atypical.

Tuberculosis of the pancreas: MRI features

OBJECTIVE

The purpose of this study was to describe the MRI features of tuberculosis of the pancreas.

CONCLUSION

Pancreatic tuberculosis can be focal or diffuse. If focal, it presents as a sharply delineated mass located in the pancreatic head, showing heterogeneous enhancement. Lesions are hypointense on fat-suppressed T1-weighted images and a mixture of hypo- and hyperintense on T2-weighted images. The appearances of common bile duct and main pancreatic duct are normal. Diffuse involvement is characterized by pancreatic enlargement with narrowing of the main pancreatic duct and heterogeneous enhancement. Signal intensity abnormalities indicating diffuse involvement include hypointensity on fat-suppressed T1-weighted images and hyperintensity on T2-weighted images.

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.

Pancreatic tuberculosis: still a histopathological diagnosis

BACKGROUND

Pancreatic tuberculosis is usually unsuspected as it can present in various forms. Though an uncommon disease, once diagnosed it is potentially curable.

PATIENTS AND METHODS

Retrospective review of the records of 9 patients with histologically proven tuberculosis of the pancreas.

RESULTS

In none of the 9 patients was a preoperative diagnosis of tuberculosis possible. The diagnoses considered included: pancreatic cancer (n = 5); acute pseudocyst (n = 1); pancreatic abscess (n = 1); chronic pancreatitis with pancreatic head mass (n = 1), and carcinoma of the colon causing massive lower gastrointestinal bleeding (n = 1). All the patients underwent surgery. The diagnosis of tuberculosis was confirmed by histopathological examination of biopsy specimens obtained at the time of laparotomy. One patient died, the remaining patients received antitubercular therapy and are doing well at a median follow-up period of 26 months.

CONCLUSION

In view of the nonspecific and variable clinical presentation and atypical radiological signs, a clinical diagnosis of pancreatic tuberculosis is usually not possible. Therefore there should be a high index of suspicion for this disease in young patients residing in endemic areas. Our experience highlights the importance of performing biopsy in apparently inoperable pancreatic mass lesions.

Two cases of pancreatic tuberculosis in nonimmunocompromised patients. A diagnostic challenge and a rare cause of portal hypertension

Pancreatic tuberculosis is very rare, especially in immunocompetent patients, and represents a diagnostic challenge. We describe 2 cases of pancreatic tuberculosis mimicking carcinoma on CT scan. In the first case, explorative laparotomy revealed granulomatous inflammation suggestive of tuberculosis. Cultured smears from the pancreatic tail tested positive for Mycobacterium tuberculosis, and the patient responded well to antituberculous medication. In the second case, fine needle aspirate revealed tuberculosis. This case is unique with regard to development of portal hypertension in pancreatic tuberculosis. Antituberculous medication achieved little improvement, then the patient was lost to follow-up. In suspicion of carcinoma the patient underwent laparotomy in another hospital. Malignancy was excluded, and a purulent necrotic pancreas was resected. The patient finally improved without any antituberculous medication and remains well. Both patients were tested HIV-negative. We summarize the etiology, clinical presentation, diagnosis and treatment of a diagnostic dilemma, which should be considered in clinical practice.

Pancreatic mass caused by Mycobacterium tuberculosis with reduced drug sensitivity

Pancreatic tuberculosis is a rare condition which should be considered in patients with a pancreatic mass, particularly if the patient is young, not jaundiced, from an area of high TB prevalence with a normal ERCP. We report a case of pancreatic tuberculosis due to Mycobacterium tuberculosis with reduced sensitivity to rifampicin and isoniazid, that was treated with rifabutin, ciprofloxacin, ethambutol and pyrazinamide following clinical failure of first-line therapy. The case presented illustrates the importance of obtaining material for culture and sensitivity testing in cases of suspected TB.