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

Angioplasty With Stent Implantation for Portal Venous Stenosis Caused by Abdominal Tuberculosis: A Case Report and Literature Review

Abdominal tuberculosis is one of common forms of extra-pulmonary tuberculosis. However, portal vein involvement leading to portal venous stenosis and portal hypertension is a rare complication in abdominal tuberculosis. Because of the non-specific presentations and insensitive response to anti-tuberculosis therapy of the lesions involving portal vein, it continues to be both a diagnostic and treatment challenge. We have reported a 22-year-old woman presented with massive ascites and pleural effusion, which was proved to be TB infection by pleural biopsy. After standard anti-tuberculosis therapy, her systemic symptoms completely resolved while ascites worsened with serum-ascites albumin gradient >11 g/L. Contrast-enhanced computed tomography and portal venography showed severe main portal vein stenosis from compression by multiple calcified hilar lymph nodes. Finally, the patient was diagnosed with portal venous stenosis due to lymphadenopathy after abdominal tuberculosis infection. Portal venous angioplasty by balloon dilation with stent implantation was performed and continued anti-tuberculosis therapy were administrated after discharge. The ascites resolved promptly with no recurrence occurred during the six-month follow-up. Refractory ascites due to portal venous stenosis is an uncommon vascular complication of abdominal tuberculosis. Portal venous angioplasty with stent placement could be a safe and effective treatment for irreversible vascular lesions after anti-tuberculosis therapy.

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.

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.

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.

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.

Peripancreatic tuberculous lymphadenopathy masquerading as pancreatic malignancy: a single-center experience

BACKGROUND AND AIM

Peripancreatic tuberculous lymphadenopathy is very rare and can be misdiagnosed with pancreatic or peripancreatic malignancies. The clinical characteristics and treatment outcome have not been well known. Herein, we investigated the accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), clinical features, and treatment outcomes.

METHODS

We retrospectively analyzed 42 patients diagnosed with peripancreatic tuberculosis between December 2004 and January 2011 at the tertiary care hospital in Korea.

RESULTS

Median age was 36 years (interquartile range, 30-55), and female was 66.7% (28/42). Nineteen patients (45.2%) had no symptoms, while the others had non-specific various symptoms. Thirteen (31.0%) had a previous history of tuberculosis. Initial impressions of the mass were pancreatic cancer in 14 (33.3%) and tuberculous lymphadenopathy in 13 patients (31.0%). EUS-FNA was performed in all 42 patients, with a diagnostic yield of pathologic examinations in 80.5%, polymerase chain reaction for tuberculosis in 42.9%, culture in 47.4%, and acid-fast bacilli staining in 10.0%. Tuberculosis is confirmed in 28 (66.7%), and probable tuberculosis in 14 (33.3%). All patients received anti-tuberculosis treatment, a 6-months regimen in 12 (28.6%) and a 9-months regimen in 28 (66.7%). Treatment response evaluated in 35 patients (83.3%) by computed tomography criteria showed complete response in 10 patients (28.6%), partial response in 23 (65.7%), stable disease in 1 (2.9%), and progressive disease in 1 (2.9%).

CONCLUSIONS

Peripancreatic tuberculous lymphadenopathy is frequently mistaken for pancreatic malignancy. EUS-FNA can be helpful for an accurate diagnosis. Complete resolution of the lesion, however, was not common on following imaging study after 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.

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.

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.

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.

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.

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

The increased reporting of tuberculosis of the pancreas is related to a worldwide increase in tuberculosis and an increase in emigration from countries where tuberculosis is endemic into countries where more sophisticated healthcare and radiological imaging are available. Three recent cases of pancreatic tuberculosis in Auckland, New Zealand, emphasize that tuberculosis should now be included in the differential diagnosis of a pancreatic mass. Diagnostic indicators include emigration from, or recent travel to, a country where tuberculosis is endemic, the association of a pancreatic mass with fever, the presence of abdominal pain and a cystic pancreatic mass in a younger male. Radiological appearances might be similar to a mucinous cystic neoplasm or could show a pancreatic mass with involvement of peripancreatic lymph nodes or a mass centred in a peripancreatic lymph node. When the diagnosis is suspected an human immunodeficiency virus test and a comprehensive screening for tuberculosis at other sites should be performed. If tuberculosis is unable to be diagnosed then pancreatic biopsy and culture is indicated. Endoscopic ultrasound with fine needle aspiration for cytology is likely to become the preferred technique. Most patients have an excellent clinical response to standard antituberculosis regimens.