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A case of isolated pancreatic tuberculosis mimicking pancreatic carcinoma
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Rationale:
Tuberculosis remains a serious menace to the health of people. Isolated hepatic tuberculosis is rare and pancreatic tuberculosis is extremely rare. The preoperative diagnosis of pancreatic tuberculosis remains a great challenge.
Patient concerns:
A 58-year-old Asian woman was referred to our hospital for evaluation of low back pain for 4 years and abdominal pain for 1 month.
Diagnoses:
Computed tomography (CT) of the abdomen showed a hypodense mass in the pancreatic head and neck with abundant calcifications, a hypodense lesion in the liver without calcification, peripancreatic lymphadenopathy, calcifications in some lymph nodes. CT-guided fine needle aspiration biopsy of the hepatic lesion was carried out and the cytological examination revealed hepatic tuberculosis.
Interventions:
The patient was treated with antituberculous therapy for 1 year.
Outcomes:
Low back pain and abdominal pain disappeared 3 months after initial treatment and after 2 year of follow-up, the patient was asymptomatic.
Lessons:
Our data hint that calcifications in both pancreatic lesions and peripancreatic lymph nodes may suggest pancreatic tuberculosis rather than pancreatic malignancy.
The computed tomography (CT) scans of 27 patients with abdominal tuberculosis were reviewed retrospectively to determine the range of abdominal involvement. Most patients had been at increased risk because of intravenous drug abuse, alcoholism, acquired immunodeficiency syndrome (AIDS), cirrhosis, or steroid therapy. The etiologic agent was Mycobacterium tuberculosis in 23 patients and M. avium-intracellulare in four patients with AIDS. In five patients, tuberculosis was limited to the abdomen. CT findings included adenopathy, splenomegaly, hepatomegaly, ascites, bowel involvement, pleural effusion, intrasplenic masses, and intrahepatic masses. Characteristic features were a tendency for adenopathy to prominently involve peripancreatic and mesenteric compartments, low-density centers within enlarged nodes, complex nature of the ascites, and adenopathy adjacent to sites of gastrointestinal tract involvement. Recognition of these manifestations and maintenance of an index of suspicion, especially in patients at risk, should help optimize the correct diagnosis and management of intraabdominal tuberculosis.
Problems in the management of abdominal tuberculosis are discussed with reference to 300 surgically verified cases. The protean clinical manifestations depend on the site and extent of the disease, and its complications. Operation was resorted to for complications when diagnosis was in doubt and when intrinsic intestinal disease was proved. Surgery was preceded by antituberculous drugs whenever possible. At operation, the disease was found to involve the alimentary canal in 196 cases; in the remaining 104, only the lymph nodes and/or the peritoneum were affected. Intestinal resection was carried out in 100 cases. Emergency surgery carries a high mortality (18/76) because of toxemia, hypoproteinemia, anemia, etc. Positive histology was obtained in 229 cases. One hundred and seventy-nine cases showed evidence of caseation. Caseation and peritoneal tubercles (103 cases) differentiate intestinal tuberculosis from Crohn's disease. Despite considerable progress made in therapy and prophylaxis during the last quarter of the century, tuberculosis of various sites continues to be a major health hazard in India. The precise prevalence of Koch's disease of the abdomen has not been determined due to lack of a survey in random samples of population. This common malady, however, with its protean profiles and varied complications continues to challenge the diagnostic acumen and therapeutic skill of clinicians practicing various discplines of medicine.
Medical and social progress often alter the distribution and impact of a disease. There is perhaps no disease of which this is truer than tuberculosis. The 'white plague' of centuries past has become a condition that is today not only treatable and curable, but preventable as well. Along with these major developments have come changes of a more subtle but no less important nature. Our purpose is to summarize some of these changes, place them in perspective, and point to still other innovations looming on the horizon. This review will deal with infection and disease caused by Mycobacterium tuberculosis.
Tuberculosis in the 1980s
- J Glassroth
- Ag Robins
- De Snider
- Jr
Glassroth J, Robins AG, Snider DE Jr. Tuberculosis in the
1980s. N Engl J Med 1980; 302: 1441-50.