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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 123-126

Isolated pancreatic tuberculosis: A diagnostic challenge!!


Department of Internal Medicine, BMJH, Bengaluru, Karnataka, India

Date of Submission01-Feb-2020
Date of Decision09-Feb-2020
Date of Acceptance08-Apr-2020
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. K Ramyasri
Department of Internal Medicine, BMJH, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_8_20

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  Abstract 


Isolated pancreatic tuberculosis (TB) is a very rare condition even in endemic areas. Pancreatic TB is seen in immunocompromised patients and usually occurs in association with miliary TB. Pancreatic TB can present as acute or chronic pancreatitis, a pancreatic abscess, and solid pancreatic masses. In a case of pancreatic mass, the possibility of TB should be considered in the list of differential diagnoses. Endoscopic ultrasound fine-needle aspiration sampling with an acid-fast smear is required for diagnosing pancreatic TB. Early diagnosis and prompt management of pancreatic TB will prevent unnecessary surgery and associated morbidity to the patient. Hereby, we report a very rare case of isolated pancreatic TB in a 26-year-old female who presented with a mass in porta-hepatis, which was adherent to the head of the pancreas.

Keywords: Abdominal TB, CT scan, immunosupressive state, isolated pancreatic tuberculosis, lymph node biopsy, pancreas


How to cite this article:
Harsha N S, Supreeth S K, Lokesh P, Ramyasri K, Shekar M, Suraj B M. Isolated pancreatic tuberculosis: A diagnostic challenge!!. APIK J Int Med 2021;9:123-6

How to cite this URL:
Harsha N S, Supreeth S K, Lokesh P, Ramyasri K, Shekar M, Suraj B M. Isolated pancreatic tuberculosis: A diagnostic challenge!!. APIK J Int Med [serial online] 2021 [cited 2021 Jun 12];9:123-6. Available from: https://www.ajim.in/text.asp?2021/9/2/123/314203




  Introduction Top


Tuberculosis (TB) involving the pancreas is very rare, especially in immunocompetent patients. Pancreatic TB commonly occurs in a patient with underlying miliary TB or disseminated disease. Isolated pancreatic TB is a very rare condition.[1] Pancreatic TB manifesting as discrete pancreatic mass will mislead the physician and falsely be labeled as a malignant mass. Endoscopic ultrasound-fine-needle aspiration (EUS-FNA) is the main modality to diagnose pancreatic TB.[2] The excellent response to antitubercular therapy makes it imperative to diagnose pancreatic TB early, and unnecessary surgical interventions can be avoided. A high index of suspicion is needed for the diagnosis of pancreatic TB. We report one such case of isolated pancreatic TB, presented as a pancreatic mass, which was surrounding the portal vein and compressing the common hepatic duct, where early prompt cytological diagnosis and appropriate management prevented unnecessary surgery and morbidity to the patient.


  Case Report Top


A 26-year-old female, resident of Bengaluru, presented to the medicine outpatient department with complaints of pain abdomen, vomiting, and loss of weight for 2 months. Vomiting was nonprojectile, nonbilious, and about 2–3 episodes/day. Pain abdomen was predominantly in the epigastric region, which was nonradiating and occasionally associated with nausea. She had a history of losing weight of 4 kg over 2 months' duration. She denied any history of fever, jaundice, night sweats, hematemesis, melena, burning micturition, and persistent cough. She had no history of significant comorbid illnesses in the past and no history of chronic drug intake. There was no significant history of malignancy or gastrointestinal disorders or TB in the family.

On examination, the patient was thin built with mild epigastric tenderness but not associated with guarding or rigidity on palpation. Routine laboratory investigations showed normocytic normochromic anemia with hemoglobin of 10.3 g/dl. Liver function tests were normal except alkaline phosphatase being raised to 418.9 U/L. Serum lipase and amylase were not elevated. Renal function tests and coagulation profile were found to be normal.

Chest X-ray was normal. Ultrasonography (US) of the abdomen showed hypoechoic lesion of size 50 mm × 38 mm near the head of the pancreas with very less vascularity as shown in [Figure 1]. Subsequently, she underwent an abdominal computed tomography (CT) scan, which revealed a large mass seen in the porta hepatis with multiple, small necrotic/liquefy areas as shown in [Figure 2]. The mass was adherent to the head of the pancreas. The common hepatic duct was compressed by the mass. The portal vein was encased in the mass. EUS with FNA of periportal nodal mass was done, which showed features of necrotizing granulomatous inflammation. Peripancreatic lymph node biopsy was done, which showed caseating granulomatous inflammation as shown in [Figure 3].
Figure 1: Sonography of the abdomen showing hypoechoic lesion near the head of the pancreas with minimal vascularity

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Figure 2: Contrast-enhanced computed tomography of the abdomen and pelvis showing mass in the porta hepatis measuring 5.6 cm × 4.4 cm. The mass shows multiple, small necrotic/liquefy areas. The portal vein is encased in the mass and the mass is adherent to the inferior vena cava and the head of the pancreas

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Figure 3: Histopathological study of lymph node biopsy. Specimen showing Ziehl–Neelsen staining of a lymph node biopsy from the pancreatic region, which reveals granulomatous inflammation

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We had diagnosed the patient as pancreatic TB based on cytological reports. Her retroviral status was found to be negative. She was started on antitubercular treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol as per the revised national tuberculosis control programme (RNTCP) guidelines. The patient had completed the course. She had improved clinically. Follow-up CT abdomen study showed resolution of the size of the lesion.


  Discussion Top


While TB is a major health concern worldwide, isolated pancreatic TB is a very rare condition including in endemic areas. In 1944, Erich Auerbach, a German scholar, in an autopsy series had reported pancreatic involvement in 4.7% of biopsies in cases of miliary TB.[3] TB is a potentially serious infectious disease, which usually involves various organ systems of the human body, caused by various strains of Mycobacterium, most commonly Mycobacterium tuberculosis. As per the World Health Organization report 2013, around 9 million people had TB and 1.5 million died due to the disease, with the highest incidence of infection occurring in Asia, South America, Eastern Europe, and most of the sub-Saharan African countries.[4]

TB most commonly involves lungs, although extrapulmonary TB (EPTB) accounts for around 20% of TB cases among immunocompetent hosts and around 50% of TB cases in patients with immunodeficiency. EPTB can occur in any organ system, with the most common sites of infection being the lymph nodes and pleura.[4]

Abdominal TB is the sixth most common condition, which includes infection anywhere in the gastrointestinal tract, both peritoneum and solid organs such as liver and spleen. Isolated pancreatic TB is extremely uncommon, with the incidence being <4.7% in the world. Pancreatic involvement of TB usually affects the young population of 21–40 years' age group with no sex differences, affects people living in endemic areas of TB, in the setting of miliary or widely disseminated TB, and is more common in immunocompromised hosts.[1],[4],[5] The mechanism of spread of TB to pancreas may occur by direct extension to the organ through hematogenous spread and very rarely lymphatic, or by reactivation of previous TB infection in an immunosuppressive state.[6]

Pancreatic TB most commonly affects the head or body of the pancreas, and very rarely, tail of the pancreas.[7] Pancreatic TB can present with nonspecific or constitutional symptoms such as epigastric pain, fever, anorexia, weight loss, night sweats, low backache, malaise, jaundice, and pancreatic mass.[8] Individuals may also present with gastrointestinal hemorrhage secondary to splenic vein thrombosis. Pancreatic neoplasm is considered the nearest differential sharing similar clinical and radiological findings as that of pancreatic TB. Pancreatic TB is often misdiagnosed due to the low index of suspicion and it's symptoms mislead to other more common pancreatic conditions like pancreatic malignancy.[9]

Pancreatic TB should be considered in the differential diagnosis of focal pancreatic lesions, especially in areas with an increased burden of TB. If the diagnosis is delayed, pancreatic TB can be fatal with a mortality rate of 10.8% (comparing to the mortality rate of 9.1% in immunocompetent patients). However, pancreatic TB gets resolved completely to standard antitubercular regimen.[10]

While evaluating for a solid mass in the head of the pancreas, always look for pancreatic cancer, metastatic disease, chronic and autoimmune pancreatitis, and fungal infections apart from TB. Even in pancreatic TB, very rarely, few patients may present with jaundice secondary to obstruction of a biliary duct due to compression by enlarged mass, which may mislead as pancreatic malignancy.[11]

There are no particular radiologic features that are pathognomonic for pancreatic TB. US shows a bulky pancreas with cystic or solid mass appearance though not diagnostic. CT features of pancreatic TB usually include hypodense, minimally vascularized, well-defined mass with irregular margins and central multiloculated appearance with adjacent necrotic and nonnecrotic lymphadenopathy.[12]

Fine-needle aspiration cytology (FNAC) is the easiest method for diagnosis. It helps in confirming TB and ruling out malignancy. FNAC is usually done under imaging (US/EUS/CT) guidance, and tissue sampling is sent for histopathological examination. EUS-FNA along with histopathological study is considered the investigation of choice for pancreatic TB.[2]

Biopsy is usually taken from the pancreatic lesion or peripancreatic lymph node. Acid-fast bacilli are not commonly seen with FNAC study, but reveal granulomatous inflammation which is pathognomonic of TB. Always consider to do HIV testing in all patients suspected to have pancreatic TB.

Pancreatic TB is very difficult to diagnose, but once diagnosed, it has a good prognosis. Pancreatic TB usually responds well to standard anti-TB treatment for 6–12 months[13] and the patient achieves complete cure. However, in case of biliary obstruction due to mass compression, the patient may need surgical intervention to relieve obstruction despite antitubercular treatment. For follow-up, CT imaging will be helpful to look at the complete resolution and response to antitubercular therapy.


  Conclusion Top


Pancreatic TB should be considered in the differential diagnosis of patients presented with pancreatic masses, especially in areas where TB is endemic. It is very difficult to diagnose pancreatic TB only based on imaging because in many cases, it may resemble pancreatic neoplasm. Hence UT/CT/endosonography-guided biopsy is the investigation of choice. An attempt for early identification and diagnosis is crucial during evaluation. Usually, many of the patients achieve complete cure with standard antitubercular treatment, which helps in the reduction of morbidity and mortality to the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaushik N, Schoedel K, McGrath K. Isolated pancreatic tuberculosis diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report. JOP 2006;7:205-10.  Back to cited text no. 1
    
2.
Chatterjee S, Schmid ML, Anderson K, Oppong KW. Tuberculosis and the pancreas: A diagnostic challenge solved by endoscopic ultrasound. A case series. J Gastrointestin Liver Dis 2012;21:105-7.  Back to cited text no. 2
    
3.
Watanapa P, Vathanopas V. Tuberculous pancreatic abscess: A rare condition mimicking carcinoma. HPB Surg 1992;5:209-11.  Back to cited text no. 3
    
4.
Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004;120:316-53.  Back to cited text no. 4
    
5.
Rana SS, Sharma V, Sharma R, Bhasin DK. Involvement of mediastinal/intra-abdominal lymph nodes, spleen, liver, and left adrenal in presumed isolated pancreatic tuberculosis: An endoscopic ultrasound study. J Dig Endosc 2015;6:15.  Back to cited text no. 5
  [Full text]  
6.
Liu Q, He Z, Bie P. Solitary pancreatic tuberculous abscess mimicking prancreatic cystadenocarcinoma: A case report. BMC Gastroenterol 2003;3:1.  Back to cited text no. 6
    
7.
Woodfield JC, Windsor JA, Godfrey CC, Orr DA, Officer NM. Diagnosis and management of isolated pancreatic tuberculosis: Recent experience and literature review. ANZ J Surg 2004;74:368-71.  Back to cited text no. 7
    
8.
Xia F, Poon RT, Wang SG, Bie P, Huang XQ, Dong JH. Tuberculosis of pancreas and peripancreatic lymph nodes in immunocompetent patients: Experience from China. World J Gastroenterol 2003;9:1361-4.  Back to cited text no. 8
    
9.
Crowson MC, Perry M, Burden E. Tuberculosis of the pancreas: A rare cause of obstructive jaundice. Br J Surg 1984;71:239.  Back to cited text no. 9
    
10.
Jenney AW, Pickles RW, Hellard ME, Spelman DW, Fuller AJ, Spicer WJ. Tuberculous pancreatic abscess in an HIV antibody-negative patient: Case report and review. Scand J Infect Dis 1998;30:99-104.  Back to cited text no. 10
    
11.
Chaudhary A, Negi SS, Sachdev AK, Gondal R. Pancreatic tuberculosis: Still a histopathological diagnosis. Dig Surg 2002;19:389-92.  Back to cited text no. 11
    
12.
Bhatia V, Garg PK, Arora VK, Sharma R. Isolated pancreatic tuberculosis mimicking intraductal pancreatic mucinous tumor. Gastrointest Endosc 2008;68:610-1.  Back to cited text no. 12
    
13.
Rana SS, Bhasin DK, Rao C, Singh K. Isolated pancreatic tuberculosis mimicking focal pancreatitis and causing segmental portal hypertension. JOP 2010;11:393-5.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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