A 47 year old woman presented with a 2-month history of pain in the upper abdomen associated with significant weight loss.
There was no history of jaundice, pruritis, vomiting, gastrointestinal bleeding or fever. General physical and systemic examination was normal. On laboratory investigation, total leukocyte count was 8900/mm3. Erythrocyte sedimentation rate was 55mm in the first hour. Abdominal US demonstrated a hypoechogeneous pancreatic parenchymal tumefaction without dilating the common bile duct. Post-contrast CT revealed heterogeneous and low density voluminous process of the corpus of the pancreas (Fig 1). This lesion was extending on posterior and surrounding superior mesenteric artery, without thrombus (Fig 2). It was of soft tissue density, without necrosis. Diagnosis of a malignancy tumour was evocated. The head of pancreas was normal. The common bile duct measured 6mm and the principal main pancreatic duct was no dilated. There were no distant metastases.
Explorative laparotomy was performed. The pancreas appeared oedematous and founded the processus of the pancreas. There were a multiple peripancreatic lymph nodes. Biopsy of the mass and the lymph nodes was performed.
Histopathological examinations revealed caseating granuloma and confirmed tuberculosis.
Radiologic chest was normal and there was no another tuberculosis manifestation.
The patient was started on anti-tubercular therapy with four drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) for 2 months followed by tow drugs (isoniazid and rifampicin) for 10 months. After one year of treatment, the symptoms disappeared and resolution of the pancreatic mass on ultrasound was observed.
Tuberculosis of the abdomen is seen in 12% of patients with military tuberculosis. Isolated involvement of the pancreas is an extremely rare condition, more so in an immunocompetent individual. The incidence has been reported to be around 0-4.7% .
Pancreatic tuberculosis usually affects young adults with equal sex distribution. This can produce a variety of clinical presentations. They include pancreatic abscesses, acute or chronic pancreatitis, portal vein compression or obstruction with resultant hypertension, gastrointestinal bleeding, new onset diabetes and obstructive jaundice mimicking pancreatic malignancy [1,2].
Infection is said to involve the pancreas by direct extension, lymphohematogeneous dissemination or following reactivation of previous abdominal tuberculosis .
The most common complaint of pancreatic tuberculosis is abdominal pain (66%) followed by fever (52%), anorexia (42%), malaise (28%), back pain (20%) and jaundice (15%).
Radiological investigations are useful aid to diagnosis . Ultrasound can detect pancreatic masses in up to 80% of cases. On contrast enhanced CT imaging, pancreatic tuberculosis usually appears as a focal hypodense mass mimicking solitary cystic pancreatic mass which may be accompanied with peripancreatic lymphadenopathy, more rarely it appears as diffuse pancreatic enlargement [1,2]. In our patient, pancreatic tuberculosis presented like parenchymal pancreatic mass.
However, the differential diagnosis for a pancreatic mass includes a variety of conditions. peripancreatic tuberculous lymphadenitis can be mis-diagnosed as an abdominal neoplasm, pancreatitis or pancreatic lymphoma. Biopsy may help in establishing the diagnosis early. Techniques used include endoscopic ultrasound guide biopsy, CT/ US guided biopsy or even laparoscopic surgical biopsy .
Following diagnosis, antituberculous microbial therapy should be commenced. Initially, quadruple therapy is advised until sensitivities are available after which the regime can be rationalised. Treatment should be for a period of at least one year.
Differential Diagnosis List