Isolated pancreatic tuberculosis mimicking as carcinoma: a case report and review of the literature.

Abstract

Pancreatic tuberculosis is a rare disease even in endemic countries for tuberculosis. Here, we report a case of pancreatic tuberculosis from tuberculosis endemic zone presenting as obstructive jaundice mimicking pancreatic cancer.
A 41-year-old male presented with features of malignant obstructive jaundice. Ultrasonography and computed tomography scan showed mass in the pancreatic head and uncinate process. He underwent a pancreatoduodencetomy. Histological examination showed typical features of tuberculosis. Antitubercular drugs were started and he remains well six months after surgery.
Tuberculosis should be considered as a differential diagnosis to an obscure pancreatic mass in younger or middle aged patient residing in tuberculosis endemic zone.

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CASE REPORTOpen Access
Isolated pancreatic tuberculosis mimicking as
carcinoma: a case report and review of the
literature
Sudeep Khaniya1*, Rabin Koirala1, Vikal Chandra Shakya1, Shailesh Adhikary1, Rajendra Regmi1, Sagar Raj Pandey2,
Chandra Shekhar Agrawal1
Abstract
Introduction: Pancreatic tuberculosis is a rare disease even in endemic countries for tuberculosis. Here, we report
a case of pancreatic tuberculosis from tuberculosis endemic zone presenting as obstructive jaundice mimicking
pancreatic cancer.
Case presentation: A 41-year-old male presented with features of malignant obstructive jaundice. Ultrasonography
and computed tomography scan showed mass in the pancreatic head and uncinate process. He underwent a
pancreatoduodencetomy. Histological examination showed typical features of tuberculosis. Antitubercular drugs
were started and he remains well six months after surgery.
Conclusion: Tuberculosis should be considered as a differential diagnosis to an obscure pancreatic mass in
younger or middle aged patient residing in tuberculosis endemic zone.
Introduction
Tuberculosis (TB) is a common disease in developing
countries, and even in developed countries, it is becom-
ing important, especially with the rise of acquired
immunodeficiency syndrome and widespread use of
immunosuppressant drugs. Pancreatic TB is considered
to be extremely rare. Most cases of pancreatic TB are
diagnosed only after tissue biopsy or exploratory lapar-
otomy. Because almost all cases of pancreatic TB are
effective to antituberculosis management, every effort
should be made to arrive at an early diagnosis so as to
avoid unnecessary interventions, including laparotomy.
Here we present a case of TB in the pancreatic head
and uncinate process mimicking pancreatic carcinoma
in a 41 year-old male.
Case presentation
A 41-year-old Nepalese male of Aryan origin presented
with 3 months history of gradually progressive jaundice,
intermittent right upper quadrant pain, and weight loss
of 5 kg over a 2-month period. There was no history of
cough, fever, hemoptysis or shortness of breath. He had
received a BCG vaccine at childhood, but there was no
prior history of tuberculosis, or family history of contact.
On examination, patient was deeply icteric with skin
scratch marks all over the body. On abdominal exami-
nation, he had mild hepatomegaly and a palpable gall
bladder. Initial laboratory values revealed a WBC count
of 9200/mm3(90% neutrophils, 10% lymphocytes), hae-
moglobin 12.7 g/dL, total bilirubin 24.4 mg/dL, conju-
gated bilirubin18 mg/dL, ALT 96 U/L (normal 5-45 U/
L), AST 161 U/L (normal 5-45 U/L), and ALP 593 U/L
(normal 42-128 U/L), albumin 3.5 mg/dL and total pro-
tein 5.7 mg/dL. His random blood sugar, serum urea
and creatinine will within normal limits. A chest X-ray
film was normal. Abdominal ultrasound examination
revealed an irregular hypoechoic lesion of 3 cm × 4.4
cm in the head and uncinate process of pancreas, and
with dilation of entire bile duct system, distended gall
bladder with normal pancreatic duct. Contrast enhanced
CT scan showed a heterogeneous mass in the pancreatic
head and uncinate process of the pancreas. (Figure 1)
The gall bladder was distended along with the dilatation
of entire biliary tract. Exploratory laparotomy revealed a
* Correspondence: khaniya_bpkihs@yahoo.com
1Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan,
Nepal
Khaniya et al. Cases Journal 2010, 3:18
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© 2010 Khaniya et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
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mass of size 3×2 cm at the head and uncinate process of
pancreas with areas of necrosis on cut section, 50 ml of
thick pus at the retroduodenal region, dilated distal
common bile duct, distended gall bladder and multiple
enlarged perichodochal and peripancreatic lymph nodes.
The patient underwent pancreatoduodencetomy with
intraoperative diagnosis of pancreatic carcinoma. AFB
staining of the pus was negative and culture was sterile.
However, the histopathology from the pancreatic mass
revealed necrotizing granulomatous lesion which was
positive for acid fast bacilli. The histopathological pic-
ture of the enlarged nodes was of reactive lymphadeni-
tis. (Figure 2) The patient had uneventful postoperative
period. After the diagnosis of tuberculosis, antitubercu-
lar drugs were started in accordance to DOTS (Directly
observed treatment, short-course), and patient is doing
well at the follow up after 6 month.
Discussion
Tuberculosis is a major public health problem in devel-
oping countries. Though TB commonly occurs in lung,
primary abdominal TB is not uncommon, incidence ran-
ging from 0.58% to 12% [1]. But contrary to belief, only
6-38% of patient with active pulmonary TB have abdom-
inal TB [2]. TB does easily disseminate to the gastroin-
testinal tract, liver, spleen and mesenteric lymph nodes;
however the involvement of pancreas is rare. The first
report pancreatic TB mimicking cancer was reported by
Auerbach in 1944. In his series of 1656 autopsies of
tuberculous patients, only 14 cases had direct pancreatic
involvement that may have mimicked neoplasia [3]. Since
then, most of the medical literature on this rare disease is
limited to case reports or small case series. There have
been reported incidents in the past where extensive sur-
geries have been performed for high suspicion of periam-
pullary carcinomas which later turned out to be
tuberculosis of the pancreas [4]. Feng Xia et al. have sum-
marized characteristics of pancreatic TB as follows: 1)
mostly occurs in young people, especially female; 2) have
a past history of TB, or come from endemic zone of
active tuberculosis; 3) often present with epigastric pain,
fever and weight loss; 4) ultrasound and CT scan show
pancreatic mass and peripancreatic nodules, some with
focal calcification [5]. The other reported presentation of
pancreatic TB is as follows; obstructive jaundice, gastro-
intestinal bleed, acute or chronic pancreatitis, pancreatic
abscess, portal venous thrombosis causing portal hyper-
tension and even colonic perforation [6,7].
Even though, the disease occurs commonly in patients
residing in endemic zones, or in those with immunosup-
pressant status, the diagnosis of pancreatic TB is a real
challenge. The challenge is partly because of rarity of the
disease itself and partly due to its insidious presentation,
with nonspecific signs and symptoms or mimicking pan-
creatic carcinoma like in the present case. Even though
the patient belonged to TB endemic zone, due to its unu-
sual presentation we suspected of malignancy and he was
managed with extensive but albeit unnecessary resection.
There are other reports also in which pancreatic TB has
not been diagnosed preoperatively [1,4,6]. In Saluja et al
study, out of 18 patients 4 patients had pancreatic TB and
all required operative resection for diagnosis [4].
The noninvasive diagnostic techniques for pancreatic
TB rely mainly on ultrasonography and CT abdomen.
Ultrasonography reveals focal hypoechoic lesions or cys-
tic lesions of the pancreas [8]. Findings on CT scan
Figure
heterogeneous lesion in the head and uncinate process of
pancreas with non enhancing areas suggestive of necrosis
(arrow) and distended gall bladder.
1
Contrastenhanced CT abdomenshowing
Figure 2 Photomicrograph showing pancreatic parenchyma
destroyed by granuloma (×400 H&E stain).
Khaniya et al. Cases Journal 2010, 3:18
http://www.casesjournal.com/content/3/1/18
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include hypodense lesions and irregular borders mostly
in the head of the pancreas, diffuse enlargement of the
pancreas or enlarged peripancreatic lymph nodes [9].
Bile cytology or ERCP has low diagnostic yield estimated
around 5% [4]. In contrast to noninvasive techniques,
invasive diagnostic techniques are more reliable and
definitive as tissue obtained from biopsy can be assessed
for microbiological and pathologic examination. Techni-
ques for biopsy include endoscopic US-guided biopsy,
CT/US- guided percutaneous biopsy, and surgical biopsy
(open or laparoscopic) [10]. The microscopic features
suggestive of tuberculosis are presence of caseating
granulomatous inflammation and positive stain for acid-
fast bacilli. Cultures for mycobacteria take up to 6
weeks to grow and are used to confirm the diagnosis.
However, it must be remembered that bacteriological
confirmation may not be possible in many patients [11].
The polymerase chain reaction-based assay is a highly
specific assay and may give a positive result even when
special staining techniques and cultures of these tissues
are negative [12].
Once the tissue diagnosis has been made, the manage-
ment of TB rest on the medical treatment. The treat-
ment of pancreatic tuberculosis comprises multi-drug
anti-tuberculous chemotherapy for between 6 and 12
months. The DOTS guidelines recommend only six
months of therapy even for severe forms of tuberculosis
[13]. Response to therapy is predictable and complete.
Longer duration of treatment results in higher costs and
exposes patients to more side effects.
Conclusion
Pancreatic TB is a rare disease requiring high index of
suspicion for diagnosis. Unfortunately, in most cases the
diagnosis of pancreatic TB is made only after explora-
tory laparotomy, as in the present case. Therefore the
diagnosis of pancreatic TB should be considered in the
context of a mass in the head/uncinate process of the
pancreas in younger patients from endemic TB zone or
in the immunocompromised patients, and vigorous
attempts should be made to obtain preoperative micro-
biological and/or histological diagnosis.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Abbreviations
ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate
aminotransferase; CT: computed tomography; DOTS: directly observed
treatment shortcourse; ERCP: endoscoic retrograde
cholangiopancreatography; TB: tuberculosis; US: ultrasonography; WBC: white
blood count.
Author details
1Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan,
Nepal.2Department of Pathology, B. P. Koirala Institute of Health Sciences,
Dharan, Nepal.
Authors’ contributions
SK and RK made substantial contributions to concept and design of the
article. VCS, RR and SRP were involved in the acquisition of materials. CSA
and SA contributed significantly in the critical revision and drafting of the
manuscript. All authors read and approved the final version of the
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 30 November 2009
Accepted: 12 January 2010 Published: 12 January 2010
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Cite this article as: Khaniya et al.: Isolated pancreatic tuberculosis
mimicking as carcinoma: a case report and review of the literature.
Cases Journal 2010 3:18.
Khaniya et al. Cases Journal 2010, 3:18
http://www.casesjournal.com/content/3/1/18
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