A pseudotumoral presentation of pancreatic tuberculosis

Abstract

A 22-year-old female, with no particular past medical history except for consumption of raw milk, was hospitalized with symptoms of severe epigastric pain, penetrating to the back and associated vomiting; symptoms were progressive over a one-month period. She had no other change in her general health. Examination revealed no signs of clinical tuberculosis (sweats, weight loss, hemoptysis). Laboratory findings and tumor markers were normal.Abdominal CT revealed a heterogeneous tumoral mass in the pancreatic isthmus and body, measuring 6 × 4.5 cm (Fig. 1); the mass appeared partially necrotic and there was extensive celiac mesenteric lymphadenopathy, infiltration of the peri-pancreatic fat, and moderate ascites. The peritoneum and omentum had a scalloped irregular border, particularly in the peri-colic gutters, and a nodule in the right iliac fossa was suggestive of peritoneal carcinomatosis.Diagnostic laparoscopy showed hypertrophy of the pancreas, mainly in the area of the isthmus and body, associated with numerous nodules studding the pancreatic capsule and peritoneum; this had the appearance of disseminated peritoneal carcinomatosis (Fig. 2). Biopsies of these nodules showed epithelioid granulomas with giant cells, diagnostic of pancreatic and peritoneal tuberculosis. The remainder of the diagnostic testing, including chest X-ray, and acid-fast staining of sputum and urine was negative. The patient was treated with quadruple antituberculous antibiotic therapy with isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months, followed by another 6 months of two-drug therapy with isoniazid and rifampin. Follow-up abdominal CT at 3 months after initial therapy confirmed the disappearance of the pancreatic lesion; the pancreas was of normal size with homogeneous enhancement and conserved lobularity (Fig. 3). DiscussionOur case is a good illustration of the difficulties inherent in characterizing a deep mass by imaging. The images of this lesion were strongly evocative of a tumoral mass, despite the young age of our patient. Pancreatic tuberculosis is a rare entity and is usually associated * Corresponding author. Tel.: +216 98 63 93 53.

Pancreatic Tuberculosis

“…These features may resemble these of inflammatory or neoplastic cystic lesions of the pancreas. In a study by Nagar et al [5], CT showed hypodense collections within the pancreas associated with peripancreatic lymphadenopathy in 29 patients [32] 2007 Pancreatic abscesses and colonic perforation Nakai et al [33] 2007 Pancreatbiliary fistula Chang et al [7] 2008 Progressive dysphagia Pandita et al [14] 2009 Dyspepsia Rana et al [34] 2010 Focal pancreatitis and segmental portal hypertension Hellara et al [35] 2012 Pseudotumoral presentation while 3 patients had a complex pancreatic mass lesion. Xia et al [6] in a study on 16 patients reported that CT showed pancreatic mass with heterogenous hypodensity focus in all patients with calcification in 9 patients and peripancreatic nodules in 6 patients.…”

Pancreatic Tuberculosis with Vascular Involvement and Peritoneal Dissemination in a Young Man

“…A spectrum of manifestations during the development of pancreatic TB is really diverse, ranging from abdominal discomfort, abdominal pain, nausea and vomiting, obstructive jaundice, loss of appetite, and weight loss to fever, night sweats, or abdominal mass [ 9 – 11 ]. Although there are so many symptoms for TB, patient always afflicts one or more kinds of presentations, as is demonstrated here.…”

“…Based upon these, some neoplastic disease cannot be excluded although the patient was not old. When the pancreatic carcinoma or neoplasm occurred, the most common symptoms are turned to pain, weight loss, jaundice, and anorexia, which will become more and more serious [ 8 , 9 ]. In our case, we found that the malignancy should be highly suspected because the radiology defined exactly that a mass had low density, compressed the surrounding organs, and wrapped the blood vessels.…”