Pancreatic tuberculosis: A systematic review of symptoms, diagnosis and treatment

Pancreatic masses clinically diagnosed as tuberculosis: Case reports

Pancreatic masses are commonly encountered in clinical practice, with concern for the possibility of cancer. Tissue sampling or outright surgical resection may be offered in this setting. However, surgery has been unnecessarily performed in patients with pancreatic masses that proved to be benign. Less invasive options for pancreatic masses that may be benign like tuberculosis should thus be explored. Three adult Filipino patients less than 60 years old presented with symptomatic pancreatic masses suspected of cancer on abdominal imaging studies. Two were smokers without a history of prior tuberculosis. Without any tissue sampling, anti-tuberculosis treatment was eventually given to all three patients due to concomitant diagnoses of extrapancreatic tuberculosis. Endoscopic ultrasound documentation of post-treatment resolution of pancreatic masses was noted in all cases. In endemic regions, although clinical diagnosis of tuberculosis may be possible for pancreatic masses, empiric treatment should still be a last-line option in cases where tissue sampling cannot be done.

Tuberculosis and diabetes mellitus: The complexity of the comorbid interactions

The double burden of tuberculosis (TB) and diabetes mellitus (DM) represents a major public health challenge that demands urgent and integrated approaches. The interplay between these two chronic conditions presents unique clinical and public health management challenges, as well as social and economic implications. We explored the bidirectional relationship between TB and DM, emphasizing how DM increases susceptibility to TB and complicates its management, while TB may exacerbate glycaemic control in diabetic patients. This review underscores the challenges associated with the management of both diseases, obstacles in screening TB patients for DM and TB preventive therapy for DM since inadequate glycaemic control can impact treatment outcomes. Several studies have investigated the disease interplay; however, the results have been equivocal, and this may be exerting negative impacts on the disease prevention and treatment. TB-diabetes comorbidity has been linked to poor treatment outcomes whereas TB prevention in people with DM at present is a dilemma. In addition to highlighting how urgent it is to address this comorbidity, this review offers a road map for better prevention, treatment, and control of several factors underlying the TB-diabetes syndemic interaction.

The WHO system versus the Papanicolaou society of cytopathology system for reporting pancreaticobiliary cytology for risk stratification-which is better?

BACKGROUND

Recently, the World Health Organization (WHO) has proposed a reporting system for pancreaticobiliary cytopathology. We applied this classification for pancreatic lesion samples by fine needle aspiration (FNA) and compared the results to the previous classification of the Papanicolaou Society of Cytopathology (PSC) system for risk stratification.

METHODS

The computerized database was searched for all pancreatic endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and transabdominal ultrasound-guided FNA (TUS-FNA) samples from 2016 to 2020 and cases were reassigned as per the PSC and the WHO diagnostic categories. Cases with follow-up, clinicoradiological, and/or histopathology were included in the study. The risk of malignancy (ROM) was calculated across all diagnostic categories based on clinical data, imaging data, and histopathology wherever available.

RESULTS

There were a total of 625 pancreatic FNA. In 230 cases, follow-up information was available which included 116 EUS and 114 TUS-FNA samples. The ROM for PSC categories I-VI was 40%, 19.7%, 28.6%, 57.1%, 94.7%, and 97.9% and for the WHO categories (I-VII), it was 60%, 21.3%, and 35.7%, not representative, not applicable, 94.7% and 94.9%. The overall sensitivity and specificity of PSC was 68.2% and 96.2% when categories V and VI were taken as positive and 78.9% and 93.3% for WHO when categories VI and VII were taken as positive.

CONCLUSIONS

Pancreatic FNA samples reported as per the WHO system showed better sensitivity as compared to the PSC system resulting in better risk stratification and consequently better patient management. The overall high specificity and moderate sensitivity reaffirm the utility of FNA in pancreatic lesions.

An Unusual Cause of Pancreatic Tumor

Pancreatic tuberculosis (TB) is a rare condition that can be challenging to distinguish from other pancreatic neoplasms. We present the case of a 48-year-old Indian male who complained of persistent vague epigastric pain for two months. Other physicians saw him and treated him like a dyspeptic case. He gave a history of daily alcohol consumption. Routine investigations, including amylase and lipase levels, were within normal limits. However, an abdominal ultrasound revealed a cystic lesion in the body of the pancreas, prompting further investigation. A subsequent abdominal CT scan revealed a tumor of 6x4 cm in diameter with solid and cystic components in the pancreatic body. Although tumor markers were not remarkable, inflammatory markers showed elevated levels of ESR (erythrocyte sedimentation rate) of 95 mm/hr and CRP (C-reactive protein) of 83 mg/L, with normal hemoglobin. Endosonography (EUS) with fine needle aspiration (FNA) was performed to achieve a definitive diagnosis. EUS was performed with a linear echoendoscope, which revealed the mass, which had solid and cystic components. Fluid was aspirated from the cystic part and FNA passes were performed in the solid part. Microscopic examination and aspirated fluid culture confirmed the presence of Mycobacterium tuberculosis, while the solid part revealed caseation-indicated granulomas, indicative of TB. The patient was promptly initiated on a seven-month course of three anti-TB medications, leading to normalization of ESR and CRP levels during the treatment period. A follow-up abdominal CT scan showed complete resolution of the pancreatic lesion, indicating successful management. This case is rare and all the data in the literature is mainly in the form of case reports. Using EUS with FNA has transformed the diagnosis of pancreatic malignancy into a curable disease that could be easily managed with anti-TB medications.

Pancreatic Tuberculosis With Duodenal Fistula Presenting as Life-Threatening Gastrointestinal Bleeding

Pancreatic tuberculosis (TB) warrants heightened suspicion in individuals with pancreatic lesions and risk factors such as HIV, organ transplantation, or pertinent immigration history. We present a 38-year-old man who presented with hemodynamically unstable gastrointestinal bleeding. He was found to have pancreatic TB complicated by a duodenal ulcer with fistula. Following 1 month of antitubercular therapy, he experienced complete resolution of symptoms, healing of the duodenal ulcer, closure of the fistulous tract, and a decrease in the size of the pancreatic lesion as observed on imaging. Our case highlights the importance of early diagnosis and treatment of pancreatic TB.

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.

Rare Solid Pancreatic Lesions on Cross-Sectional Imaging

Several solid lesions can be found within the pancreas mainly arising from the exocrine and endocrine pancreatic tissue. Among all pancreatic malignancies, the most common subtype is pancreatic ductal adenocarcinoma (PDAC), to a point that pancreatic cancer and PDAC are used interchangeably. But, in addition to PDAC, and to the other most common and well-known solid lesions, either related to benign conditions, such as pancreatitis, or not so benign, such as pancreatic neuroendocrine neoplasms (pNENs), there are solid pancreatic lesions considered rare due to their low incidence. These lesions may originate from a cell line with a differentiation other than exocrine/endocrine, such as from the nerve sheath as for pancreatic schwannoma or from mesenchymal cells as for solitary fibrous tumour. These rare solid pancreatic lesions may show a behaviour that ranges in a benign to highly aggressive malignant spectrum. This review includes cases of an intrapancreatic accessory spleen, pancreatic tuberculosis, solid serous cystadenoma, solid pseudopapillary tumour, pancreatic schwannoma, purely intraductal neuroendocrine tumour, pancreatic fibrous solitary tumour, acinar cell carcinoma, undifferentiated carcinoma with osteoclastic-like giant cells, adenosquamous carcinoma, colloid carcinoma of the pancreas, primary leiomyosarcoma of the pancreas, primary and secondary pancreatic lymphoma and metastases within the pancreas. Therefore, it is important to determine the correct diagnosis to ensure optimal patient management. Because of their rarity, their existence is less well known and, when depicted, in most cases incidentally, the correct diagnosis remains challenging. However, there are some typical imaging features present on cross-sectional imaging modalities that, taken into account with the clinical and biological context, contribute substantially to achieve the correct diagnosis.

Isolated pancreatic tuberculosis masquerading as malignancy in an immunocompetent host: a case report and review of the literature

A 41-year-old man was admitted to our department with a 7-day history of jaundice of the skin. He was misdiagnosed with carcinoma because imaging tests showed a space-occupying lesion in the pancreatic head, and laboratory examinations showed elevated liver enzymes, and elevated serum bilirubin, alpha-fetoprotein, carbohydrate antigen 19-9, and ferroprotein levels. However, there was slight calcification in the lesion and a subsequent T-Spot test result was positive. The patient then underwent endoscopic retrograde cholangiopancreatography for biopsy and bile drainage. Histologically, the pancreatic mass showed granulomatosis, and the pathologic diagnosis of the isolated pancreatic neoplasm was tuberculosis. The patient accordingly received anti-tuberculosis agents, resulting in a significant decrease in the size of the pancreatic mass. The patient recovered well. Pancreatic tuberculosis can masquerade as malignancy; however, careful attention to a differential diagnosis can prevent the need for laparotomy.

Pancreatic tuberculosis in a liver transplant recipient: a case report

The pancreatic form of tuberculosis (TB) is rare and its diagnosis is challenging, since it manifests itself with non-specific symptoms and non-pathognomonic radiological findings, mimicking a neoplasia of the pancreas. Here, we report the case of a patient who had previously undergone liver transplantation and sought care for abdominal pain, weight loss, anorexia, hematochezia and postprandial fullness. Following an exploratory laparotomy and nucleic acid amplification testing on a pancreatic sample that had been collected, the patient was diagnosed with pancreatic TB. The patient received anti-tubercular pharmacological therapy and required percutaneous biliary drainage. Awareness of the possibility of a pancreatic TB diagnosis is important for clinicians. This attention should be even greater in patients who have undergone transplants, who are immunodeficient or who are from endemic areas.

Isolated pancreatic tuberculosis masquerading pancreatic malignancy

Pancreatic tuberculosis is the rarest form of abdominal and extrapulmonary tuberculosis. We present a patient in his 40s who presented with pain abdomen and a fever. On examination, the patient had mild jaundice and right hypochondriac tenderness. Blood investigation was suggestive of obstructive jaundice. Imaging studies were representative of pancreatic head lesion, causing mild intrahepatic biliary radical dilatation. Endoscopic ultrasound-guided fine-needle aspiration done from the pancreatic head lesion was diagnostic of tuberculosis. The patient was started on antitubercular medications and responded well.

Cheesy material on macroscopic on-site evaluation after endoscopic ultrasound-guided fine-needle biopsy: Don't miss the tuberculosis

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is an excellent investigation to diagnose pancreatic lesions and has shown high accuracy for its use in pathologic diagnosis. Recently, macroscopic on-site evaluation (MOSE) performed by an endoscopist was introduced as an alternative to rapid on-site cytologic evaluation to increase the diagnostic yield of EUS-FNB. The MOSE of the biopsy can estimate the adequacy of the sample directly by the macroscopic evaluation of the core tissue obtained from EUS-FNB. Isolated pancreatic tuberculosis is extremely rare and difficult to diagnose because of its non-specific signs and symptoms. Therefore, this challenging diagnosis is based on endoscopy, imaging, and the bacteriological and histological examination of tissue biopsies. This uncommon presentation of tuberculosis can be revealed as pancreatic mass mimicking cancer. EUS-FNB can be very useful in providing a valuable histopathological diagnosis. A calcified lesion with a cheesy core in MOSE must be suggestive of tuberculosis, leading to the request of the GeneXpert, which can detect Mycobacterium tuberculosis deoxyribonucleic acid and resistance to rifampicin. A decent diagnostic strategy is crucial to prevent unnecessary surgical resection and to supply conservative management with antitubercular therapy.

Evidence-based approach to diagnosis and management of abdominal tuberculosis

Abdominal tuberculosis is an ancient problem with modern nuances in diagnosis and management. The two major forms are tuberculous peritonitis and gastrointestinal tuberculosis (GITB), while the less frequent forms are esophageal, gastroduodenal, pancreatic, hepatic, gallbladder and biliary tuberculosis. The clinicians need to discriminate the disease from the close mimics: peritoneal carcinomatosis closely mimics peritoneal tuberculosis, while Crohn's disease closely mimics intestinal tuberculosis. Imaging modalities (ultrasound, computed tomography, magnetic resonance imaging and occasionally positron emission tomography) guide the line of evaluation. Research in diagnostics (imaging and endoscopy) has helped in the better acquisition of tissue for histological and microbiological tests. Although point-of-care polymerase chain reaction-based tests (e.g. Xpert Mtb/Rif) may provide a quick diagnosis, these have low sensitivity. In such situations, ancillary investigations such as ascitic adenosine deaminase and histological clues (granulomas, caseating necrosis, ulcers lined by histiocytes) may provide some specificity to the diagnosis. A diagnostic trial of antitubercular therapy (ATT) may be considered if all diagnostic armamentaria fail to clinch the diagnosis, especially in TB-endemic regions. Objective evaluation with clear endpoints of response is mandatory in such situations. Early mucosal response (healing of ulcers at two months) and resolution of ascites are objective criteria for early response assessment and should be sought at two months. Biomarkers, especially fecal calprotectin for intestinal tuberculosis, have also shown promise. For most forms of abdominal tuberculosis, six months of ATT is sufficient. Sequelae of GITB may require endoscopic balloon dilatation for intestinal strictures or surgical intervention for recurrent intestinal obstruction, perforation or massive bleeding.

Current role of endoscopic ultrasound for gastrointestinal and abdominal tuberculosis

A high incidence of tuberculosis (TB), especially in endemic countries, makes this infectious disease a concern. Abdominal TB contributes to 10% of extrapulmonary TB. Due to nonspecific clinical, radiological, and endoscopic findings, diagnosing abdominal TB continues to be a challenge. Hence, a precise diagnosis is needed. The diagnosis of gastrointestinal disease using endoscopic ultrasound (EUS) is often performed due to its high resolution and ability to provide a real‐time visual representation of the gastrointestinal tract and extramural structures. EUS‐guided fine‐needle aspiration (FNA) and fine‐needle biopsy (FNB) have helped diagnose TB as they offer an adequate specimen for cytology or histopathological examination. This method is considered safer, more effective, and more efficient. The capacity of EUS to diagnose abdominal TB based on the affected organs was examined via a literature search. We reviewed the role of EUS in diagnosing esophageal, gastric, pancreatic, peripancreatic, hepatosplenic, peritoneal, and intestinal TB. Generally, EUS aids in diagnosing abdominal TB. In some organs, it is superior to other diagnostic modalities. However, further examinations, such as cytology or histopathology and microbial, are still needed. We also studied the roles of EUS‐FNA and EUS‐FNB. EUS‐FNA has shown a high diagnostic yield in esophageal (94.3–100%), pancreatic and peripancreatic (76.2%), and intestinal TB (84.1%). As minimally invasive methods, EUS‐FNA and EUS‐FNB can successfully provide sufficient samples. EUS is a functional diagnostic modality for abdominal TB. EUS‐FNA and EUS‐FNB provide sufficient samples safely and efficiently for further cytology, histopathology, and microbial examinations.

Pancreatic Tuberculosis-A Condition That Mimics Pancreatic Cancer

Tuberculosis is a disease with serious consequences in terms of morbidity and mortality. Pancreatic localization is very rare and is mostly encountered in patients with immunosuppressive disorders. A 59-year-old woman with arterial hypertension, grade 2 obesity, and a history of cholecystectomy, was admitted for fever (38.5 °C), jaundice, and marked physical asthenia. The blood tests showed severe metabolic acidosis, with partial respiratory compensation, mild microcytic normochromic anemia, inflammatory syndrome, procalcitonin value ten times the upper limit of normal, nitrogen retention syndrome, hypoalbuminemia, hypertriglyceridemia, hypercholesterolemia, and moderate hyponatremia. The electrocardiogram, chest X-ray, and abdominal ultrasound did not show any significant pathological changes. Contrast-enhanced computed tomography raised the suspicion of acute-on-chronic pancreatitis and subsequent evaluation by magnetic resonance imaging raised the suspicion of a pancreatic tumor. Pancreatic fine needle biopsy under echoendoscopic guidance revealed purulent material, which was sent for cytological and bacteriological examination. The Ziehl-Neelsen stain showed acid-alcoholic resistant bacilli, while bacterial cultures were positive for gentamicin and tigecycline-sensitive Klebsiella. The diagnosis of pancreatic tuberculosis was established. Pancreatic tuberculosis is a very rare condition that often mimics pancreatic cancer. The peculiarity of the case is the appearance of pancreatic tuberculosis in an immunocompetent woman and the association with Klebsiella infection.

Apparent Insulin Deficiency in an Adult African Population With New-Onset Type 2 Diabetes

Identifying patients with new-onset type 2 diabetes who have insulin deficiency can aid in timely insulin replacement therapy. In this study, we measured fasting C-peptide concentration to assess endogenous insulin secretion and determine the prevalence and characteristics of patients with insulin deficiency in adult Ugandan patients with confirmed type 2 diabetes at presentation.

Methods

Adult patients with new-onset diabetes were recruited from seven tertiary hospitals in Uganda. Participants who were positive for the three islet autoantibodies were excluded. Fasting C-peptide concentrations were measured in 494 adult patients, and insulin deficiency was defined as a fasting C-peptide concentration <0.76 ng/ml. The socio-demographic, clinical, and metabolic characteristics of participants with and without insulin deficiency were compared. Multivariate analysis was performed to identify independent predictors of insulin deficiency.

Results

The median (IQR) age, glycated haemoglobin (HbA1c), and fasting C-peptide of the participants was 48 (39-58) years,10.4 (7.7-12.5) % or 90 (61-113) mmol/mol, and 1.4 (0.8-2.1) ng/ml, respectively. Insulin deficiency was present in 108 (21.9%) participants. Participants with confirmed insulin deficiency were more likely to be male (53.7% vs 40.4%, p=0.01), and had a lower body mass index or BMI [p<0.001], were less likely to be hypertensive [p=0.03], had reduced levels of triglycerides, uric acid, and leptin concentrations [p<0.001]), but higher HbA1c concentration (p=0.004). On multivariate analysis, BMI (AOR 0.89, 95% CI 0.85-0.94, p<0.001), non-HDLC (AOR 0.77, 95% CI 0.61-0.97, p=0.026), and HbA1c concentrations (AOR 1.08, 95% CI 1.00-1.17, p=0.049) were independent predictors of insulin deficiency.

Conclusion

Insulin deficiency was prevalent in this population, occurring in about 1 in every 5 patients. Participants with insulin deficiency were more likely to have high HbA1c and fewer markers of adiposity and metabolic syndrome. These features should increase suspicion of insulin deficiency and guide targeted testing and insulin replacement therapy.

Disseminated tuberculosis following invasive procedures for peripancreatic lymph node tuberculosis with portal vein obstruction: a case report

Peripancreatic tuberculous lymphadenopathy can mimic pancreatic cancer on imaging. There have only a few reports on varices from portal vein obstruction due to abdominal tuberculous lymphadenopathy. Iatrogenic disseminated tuberculosis is also rare. Herein, we present a rare case of peripancreatic tuberculous lymphadenopathy with ruptured duodenal varices due to portal vein obstruction. The patient presented to our hospital with hematemesis. Computed tomography revealed a peripancreatic mass. Duodenal varices rupture from portal vein obstruction due to pancreatic cancer were initially suspected. The patient underwent portal vein stenting for portal vein obstruction and endoscopic ultrasound-guided fine-needle aspiration for diagnosis, which revealed granulomas indicative of tuberculosis. The patient was discharged once because fine-needle aspiration did not lead to a definitive diagnosis of tuberculosis. Subsequently, he developed disseminated tuberculosis. Peripancreatic tuberculous lymphadenopathy can cause ectopic varices with portal vein obstruction. Tuberculosis should also be included in the differential diagnosis in the case of portal vein obstruction, to facilitate early treatment and avoid unnecessary surgery. Furthermore, fine-needle aspiration or portal vein stenting for tuberculous lesions can cause disseminated tuberculosis. Since a diagnosis might not be made until after several fine-needle aspirations have been conducted, careful follow-up is necessary after the procedure for such lesions.

Pancreatoduodenal Tuberculosis: A Rare Site of a Common Disease

The most common site of abdominal tuberculosis (TB) is the ileocecal region. The duodenum and pancreas are rare sites of abdominal TB. It is usually observed in immunocompromised patients with miliary or disseminated TB. Pancreatoduodenal TB is often misdiagnosed as malignancy due to a lack of specific symptoms. Here, we present a case of a 55-year-old immunocompetent man having abdominal pain, bilious vomiting, weight loss, and high-grade fever for three months. Contrast-enhanced computed tomography of the abdomen showed a localized abscess with air foci in the pancreatic head and duodenopancreatic groove. Additionally, there was retroperitoneal lymphadenopathy and mild ascites. Upper gastrointestinal endoscopy revealed an ulceroproliferative lesion in the second part of the duodenum suspicious of a malignant tumor. However, the endoscopic biopsy showed epitheloid-like histiocytes, Langerhans type of giant cells, and granuloma formation suggestive of TB. The patient responded to antitubercular treatment and became symptom-free. 

Pancreatic tuberculosis in an immunocompetent young female mimicking a malignant tumor: A case report and diagnostic radiological investigation

Tuberculosis remains the leading cause of infectious disease related death worldwide with extrapulmonary tuberculosis being particularly difficult to diagnose. Here, we report a case of pancreatic tuberculosis (PTB) in an immunocompetent young female, which mimicked a malignant tumor diagnosed by endoscopic ultrasound-guided fine needle aspiration and biopsy (EUS-FNAB). A 19-year-old Japanese female with no prior medical history presented with abdominal epigastralgia and appetite loss lasting 2 months. A solid lobular mass was observed in the pancreatic head with enhanced abdominal computed tomography and magnetic resonance imaging suggested it was a malignant pancreatic tumor. Using EUS-FNAB, granulomas with caseous necrosis and acid-fast bacilli were observed. Polymerase chain reaction results were positive for Mycobacterium tuberculosis but negative for Mycobacterium avium complex. Therefore, the patient was diagnosed with PTB. Her symptoms and radiological findings improved with a standard antituberculosis therapy. PTB is difficult to differentiate from other pancreatic diseases with Magnetic resonance imaging (MRI) patterns of T1, T2 weighted, or diffusion-weighted image (DWI) images. To investigate novel radiological diagnostics for PTB, we focused on MRI apparent diffusion coefficient (ADC) values, which have not been investigated in this context. The present case showed 0.52 × 10^-3 mm²/s; additionally, the mean value of other mass-forming pancreatic diseases, such as pancreatic cancer was 1.592 × 10^-3 mm²/s (the range: 1.015-3.025 × 10^-3 mm²/s). The range does not overlap with the present PTB case or other pancreatic diseases. Therefore, ADC values may be useful as a noninvasive radiological diagnostic method for PTB.

Pancreatic Mass: Include Tuberculosis in the Differential Diagnosis

Although abdominal tuberculosis (TB) is quite prevalent in endemic regions, involvement of the pancreas is considerably rare. We describe a case of pancreatic TB presenting as a pancreatic mass in a patient with abdominal pain and jaundice. Due to the similar presentation, it can easily be misinterpreted as a pancreatic neoplasm. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) can help confirm the diagnosis in such cases by providing histopathological evidence of Mycobacterium tuberculosis infection. The patient made a remarkable recovery post anti-tuberculous therapy (ATT) initiation. This exceptional response of pancreatic TB to conservative management makes it imperative that the condition be diagnosed promptly to avoid any futile surgical interventions and associated complications. This can only be achieved if clinicians are aware of the diagnostic possibility of pancreatic TB presenting as a mass in the pancreas.