Tuberculosis of the pancreas: MRI features

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.

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.

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.

Tuberculous Pancreatic and Liver Abscesses Presenting as Obstructive Jaundice in an Immunocompetent Patient

Isolated hepatobiliary, pancreatic, and peripancreatic tuberculosis (TB) is an extremely rare disease, particularly in immunocompetent individuals. To the best of our knowledge, the presentation of combined pancreatic and liver abscesses is a particularly uncommon presentation among the reported cases in the literature. This presents a significant challenge in clinical diagnosis. In this report, we discuss the case of a 24-year-old Nepalese man who presented with epigastric pain and jaundice. Further, tuberculous pancreatic and liver abscesses were detected by abdominal CT and MRI, which were later confirmed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with pus smear and polymerase chain reaction (PCR) test. These tests were positive for acid-fast bacilli (Mycobacterium tuberculosis). The patient responded well to anti-tubercular therapy (ATT). As the clinical presentation is often unclear and radiological imaging may be misleading, physicians should have a high index of suspicion for TB, especially if the patient is young and belongs to an area highly endemic for TB.

Primary pancreatic tuberculosis with a duodenal fistula in an immunocompetent young man

Tuberculosis (TB) is a common disease in developing countries that can virtually affect any organ in the body. The abdomen is one of the most common sites for extra-pulmonary tuberculosis. Primary Pancreatic tuberculosis (PPTB) is rare and can be clinically elusive. It is commonly encountered in immunodeficient individuals in regions endemic for TB. However, it is extremely rare in immunocompetent individuals with very few case reports in the literature. We describe a case of PPTB in an immunocompetent young man complicated with duodenal fistula. There was complete resolution of symptoms and the fistulous tract with a significant reduction of the size of the lesion on imaging after 6 months of anti-tubercular therapy (ATT).

Isolated pancreatic and peripancreatic nodal tuberculosis: A single-centre experience

Isolated pancreatic and peripancreatic nodal tuberculosis may mimic pancreatic malignancy and may result in unnecessary surgery. Being a treatable disease, it is desirable to diagnose this condition without a laparotomy. Pancreatic tuberculosis should be considered in the differential diagnosis of a peripancreatic mass if the patient is young, residing in endemic tuberculosis regions, or has had a history of tuberculosis. We report our experience with pancreatic tuberculosis. Over a period of 12 years, we have managed 16 such patients, of whom 10 were diagnosed preoperatively. In six, the diagnosis was only made after extensive surgery. All 16 patients received antitubercular drugs and were well at a median follow-up of 52 months. Although pancreatic tuberculosis can be diagnosed by modern image-guided biopsy in a fair number of patients, if a high index of suspicion is maintained, a laparotomy may still be unavoidable in a subset of patients.

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.

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.

Tuberculosis of the gastrointestinal tract and associated viscera

Tuberculosis involvement of the gastrointestinal tract, peritoneum, and associated viscera is an uncommon but well described entity. While peritoneal tuberculosis and tuberculous enteritis are more common, involvement of the esophagus, stomach, colon, rectum, anus, liver, bile ducts, gallbladder, and pancreas can occur. Diagnosis is challenging as cases often mimic neoplasm or inflammatory bowel disease. In this review we outline the pathogenesis, clinical presentation, diagnostic testing, and treatment strategies pertaining to such cases.

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.

Pancreatic Tuberculosis with Markedly Elevated CA 19-9 Levels: A Diagnostic Pitfall

Despite the high prevalence of tuberculosis (TB) in developing countries, isolated pancreatic TB is rare and is usually seen in immunocompromised patients. It presents with non-specific signs and symptoms and may mimic malignancy both clinically and radiologically. Cytologic and histologic confirmation is required to establish the definitive diagnosis. We present a case of a 25-year-old male with a pancreatic mass and markedly elevated serum cancer antigen (CA) 19-9 levels raising the suspicion of malignancy but with a histopathologic picture of TB. This case suggests that clinicians should have a heightened suspicion of pancreatic TB when faced with discrete pancreatic lesions even though elevated tumor markers may indicate malignancy. It is important to perform appropriate diagnostic testing and initiate antitubercular therapy early.

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

Pancreatic tuberculosis is very rare, but recently, there has been a spurt in the number of reports on pancreatic involvement by tuberculosis. It closely mimics pancreatic cancer, and before the advent of better imaging modalities it was often detected as a histological surprise in patients resected for a presumed pancreatic malignancy. The usual presentation involves abdominal pain, loss of appetite and weight, jaundice which can be associated with cholestasis, fever and night sweats, palpable abdominal lump, and peripheral lymphadenopathy. Computed tomography (CT) of the abdomen is an important tool for evaluation of patients with pancreatic tuberculosis. This CT imaging yields valuable information about the size and nature of tubercular lesions along with the presence of ascites and lymphadenopathy. However, there are no distinctive features on CT that distinguish it from pancreatic carcinoma. Endoscopic ultrasound provides high resolution images of the pancreatic lesions as well as an opportunity to sample these lesions for cytological confirmation. The presence of granulomas is the most common finding on histological/cytological examination with the presence of acid fast bacilli being observed only in minority of patients. As there are no randomized or comparative studies on treatment of pancreatic tuberculosis it is usually treated like other forms of tuberculosis. Excellent cure rates are reported with standard anti tubercular therapy given for 6-12 months.

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.

Isolated pancreatic tuberculosis in non-immunocompromised patient treated by Whipple's procedure: a case report

PANCREATIC tuberculosis (TB) is a rare disease and its diagnosis is difficult because of the lack of specific clinical manifestations. Computed tomography (CT) and magnetic resonance imaging (MRI) have some diagnostic values in this disease, but it is easy to misdiagnose pancreatic TB as a pancreatic tumor.1 In this article, we present a case of non-immunocompromised patient developing an isolated pancreatic TB, report the CT and MRI findings, and the surgical procedure for it.

Fine needle aspiration diagnosis of isolated pancreatic tuberculosis: A case report

Tuberculosis (TB) involving the pancreas are uncommon, especially when present in immunocompetent hosts. Pancreatic TB is more frequently associated with miliary TB or widely disseminated disease. Pancreatic TB may present as cystic or solid pancreatic masses, pancreatic abscess or acute or chronic pancreatitis. Majority of the cases are diagnosed after surgical exploration for presumed pancreatic malignancy and pre-operative diagnosis is quite difficult. However, improvement in imaging techniques and the resulting image-guided interventions gradually can obviate the need for more invasive diagnostic surgical procedures and expedite the planning of therapy. Herein, we report a rare case of isolated pancreatic TB which presented with pancreatic mass lesion in an immunocompetent host. Diagnosis was made by contrast enhanced computed tomography and guided fine needle aspiration of the pancreatic mass which revealed acid-fast bacilli on Ziehl-Neelsen stain. The case was treated successfully with antituberculous drugs. Pancreatic tuberculosis should be considered in the differential diagnosis of a pancreatic mass when the patient is young, residing in the endemic zone of tuberculosis. Every attempt should be made to diagnose the cases to prevent unnecessary operation.

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.

A space occupying lesion masquerading as pancreatic carcinoma

The coexistence of painless jaundice and a space-occupying lesion in the head of the pancreas usually signifies a diagnosis of pancreatic cancer. We present a case, where the cause of a pancreatic mass turned out to be related to tuberculosis. Tuberculosis affecting abdominal organs in isolation is uncommon, and more often forms part of disseminated disease. Pancreatic tuberculosis is very rare, especially in immunocompetent individuals. While every effort should be made to ensure that potentially operable pancreatic cancers undergo prompt surgical excision, the challenge for the future will be to make a preoperative diagnosis of pancreatic conditions that require medical rather than surgical 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.

Pancreatic islet cell amyloidosis manifesting as a large pancreas

A 39-year-old female patient presented to our hospital with epigastric pain lasting for two months. Laboratory results showed impaired glucose tolerance. Ultrasonography of the patient showed a hypoechoic, diffusely enlarged pancreas. CT revealed a large pancreas, with multiple calcifications. On MRI, a diffusely enlarged pancreas was seen hypointense on both T1- and T2-weighted images with heterogeneous enhancement after gadolinium administration. A biopsy of the pancreas revealed primary amyloidosis of islet cells. Decreased signal on T1-weighted images without inflammation findings on CT and MRI were clues for the diagnosis.

Tuberculosis versus lymphoma in the abdominal lymph nodes: a comparative study using contrast-enhanced MRI

PURPOSE

The purpose of this study was to determine the differential characteristics on MRI between tuberculosis and lymphoma in abdominal lymph nodes.

MATERIALS AND METHODS

We conducted a retrospective analysis for the counter, size, signal intensity, enhancement patterns, and anatomic distribution of lymph nodes in 57 consecutive patients with documented tuberculosis (28 patients; 49.1%) and newly diagnosed, untreated lymphoma (29 patients; 50.9%).

RESULTS

Twenty-four cases (85.7%) in the tuberculosis group were hyperintense on T2-weighted images and either hypointense or isointense on T1-weighted images with respect to the abdominal wall muscle. All cases in the lymphoma group were hyperintense on T2-weighted images and isointense on T1-weighted images with respect to the abdominal wall muscle. Concerning the main anatomic distribution of lymph nodes, the lymph nodes in the lower paraaortic region were more frequently involved in the lymphoma group (48.3%) than in tuberculosis (17.9%, p<0.05). Moreover, mesenteric lymph nodes were more often involved in tuberculosis (32.1%) than in lymphoma (6.9%, p<0.05). Tuberculous lymphadenopathy showed predominantly peripheral enhancement, frequently with a multilocular appearance; whereas lymphomatous adenopathy often demonstrated uniform homogeneous enhancement (all p<0.001).

CONCLUSION

Contrast-enhanced MRI can be useful in differentiation between these two entities.

Coexistence of pancreatic carcinoma and pancreatic tuberculosis: case report

Pancreatic tuberculosis (TB) is extremely rare and mimics pancreatic carcinoma both clinically and radiologically. This paper discusses the occurrence of 2 heterogeneous masses located in the head and tail of the pancreas in an adult male. In this patient, laparotomy was performed because of the high suspicion of pancreatic carcinoma. Intraoperative fine needle aspiration biopsy revealed the coexistence of pancreatic carcinoma with pancreatic TB, and a combined resection of the distal pancreas and spleen was successfully performed. Following surgery, the patient received standard chemotherapy for TB. At 7-month follow-up, computed tomography showed resolution of the mass in the pancreatic head. Clinicians must maintain a high index of suspicion for pancreatic TB in patients with pancreatic masses. The coexistence of malignancy and TB should be considered when patients present with multiple pancreatic masses.

Nonalcoholic, nonbiliary pancreatitis: cross-sectional imaging spectrum

OBJECTIVE

The purpose of this review is to describe the epidemiologic, etiopathogenetic, clinical, and imaging characteristics of various nonalcoholic, nonbiliary pancreatitis syndromes.

CONCLUSION

The spectrum of nonalcoholic, nonbiliary pancreatitis includes autoimmune pancreatitis, groove pancreatitis, hereditary pancreatitis, tropical pancreatitis, tuberculous pancreatitis, and metabolic pancreatitis. Advances in genetics and molecular pathology have shed new light on the etiopathogenesis and course of these syndromes. Accurate diagnosis aided by imaging findings allows optimal management.

Pancreatic tuberculosis: a clinical and imaging review of 32 cases

BACKGROUND

Tuberculosis of the pancreas is a rare entity, and anecdotal reports describing imaging features of pancreatic tuberculosis have been described in medical literature. The imaging features including computed tomography (CT) and ultrasonography in diagnosed cases of tubercular involvement of the pancreas are described, with an overview of clinical features and laboratory investigations.

MATERIALS AND METHODS

We analyzed records of 384 patients of diagnosed cases of abdominal tuberculosis for involvement of pancreas and detected 32 patients (8.33%) who had pancreatic involvement. This included 22 men and 10 women with an age range of 19 to 64 years (mean age of 42.5 years), who were detected to have pancreatic tuberculosis from 1999 to 2004 in our institute. We reviewed the clinical, radiologic (ultrasonographic and CT features), and laboratory findings of all patients. The criteria for diagnosis of tuberculosis were based on ascitic fluid adenosine deaminase level in 14 patients, fine-needle aspiration cytology of lymph nodes in 9 patients, and presence of pulmonary tuberculosis on chest radiograph, which was found in 9 patients. On follow-up, 6 months after antituberculous treatment, 25 patients showed response to anti-Koch's treatment, 3 patients had drug-resistant tuberculosis, 2 patients died, and 2 patients were lost to follow-up.

RESULTS

The male/female ratio was 2.2:1. The maximum number of patients was in the fourth decade (30-39 years). The duration of symptoms was spanning between 2 and 11 months, with a mean duration of 6 months. The most common symptom was abdominal pain localized to the epigastrium. Sixteen patients were seropositive for HIV-1 infection. Fourteen patients had history of tuberculosis of the lungs, whereas 18 patients had pancreatic and peripancreatic involvement as the primary manifestation. Ultrasonography showed bulky inhomogenous pancreas in 5 patients; solitary or multiple hypoechoic collections were observed in all 7 and 20 patients, respectively. CT findings demonstrated hypodense collections within the pancreas associated with peripancreatic lymphadenopathy in 29 patients. Three patients had a complex pancreatic mass lesion.

CONCLUSIONS

Pancreatic tuberculosis can present with a variable spectrum of imaging findings. Tuberculosis of the pancreas should be considered as a diagnostic possibility in patients who present with a pancreatic space occupying lesion associated with peripancreatic lymphadenopathy.

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.

Uncommon tumors and pseudotumoral lesions of the pancreas

Ductal adenocarcinoma is the most common tumor of the pancreas, accounting for about 80% of all pancreatic tumors. The other 20% of pancreatic tumors is represented by a heterogeneous group of pancreatic neoplasms that includes cystic pancreatic neoplasms, islet cell tumors, and the so-called rare pancreatic tumors. In addition, the pancreatic gland may present a variety of inflammatory and pseudotumoral lesions that may mimic a primary pancreatic neoplasm. These uncommon tumors and pseudotumoral lesions present a wide spectrum of imaging findings and they are often poorly understood by the radiologist, becoming a diagnostic challenge. Some of these lesions may show an appearance similar to ductal adenocarcinoma being radiologically indistinguishable. However, some of these lesions sometimes may present specific features on imaging studies that may help to characterize the mass and to suggest a correct diagnosis. Many of these uncommon tumors and pseudotumoral lesions have a different approach, therapy, and prognosis than ductal adenocarcinoma. Therefore, it is important for the radiologist to be familiar with these entities to include them in the differential diagnosis to initiate an appropriate lesion-specific workup and treatment. In the present article, we review the radiological features of uncommon pancreatic tumors, atypical manifestations of ductal adenocarcinoma, and pseudotumoral masses, focusing on those features that can be helpful for the differential diagnosis.

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.

Vascular involvement secondary to tuberculosis of the abdomen

Although involvement of the abdomen is a common site of extrapulmonary tuberculosis, involvement of abdominal vessels with complications is rare after infections with Mycobacterium tuberculosis (M. tuberculosis). Vascular complications may result from direct involvement by M. tuberculosis of the vascular wall or may occur as a consequence of local spreading from a tuberculous mass. We describe the imaging findings in two patients with proven tuberculosis of the abdomen and significant vascular complications. In one patient, "dry plastic" peritonitis and tuberculous lymphadenopathy at the level of the porta hepatis with subsequent encasement and compression of the portal vein resulted in prestenotic dilatation and varicose formation in the upper abdomen. In the other patient, bulky necrotic tuberculous lymphadenopathy, located at the splenic hilum, resulted in encasement with stenosis of the splenic vessels and subsequent splenic infarction.