Pancreatic Tuberculosis: A Puzzle for Physicians. A Rare Case and Review of Literature

Abstract

A 57-year-old female patient presented with complaints of abdominal pain and persistent vomiting for one month. The abdominal pain was predominantly in the epigastrium, non-radiating and associated with post prandial vomiting. The pain was relieved after the bout of vomiting. The patient had occasional febrile episodes and loss of appetite. The patient was a known case Chronic Calcific Pancreatitis and Diabetes Mellitus with both exocrine and endocrine deficiency. She was on pancreatic supplements and human insulin for the past 5 years. On examination, mild epigastric tenderness was present.Blood picture showed normochromic normocytic cells. Prothrombin Time (PT), Liver Function Tests (LFT), Thyroid Function Tests (TFT), serum calcium and Parathormone levels were normal. Serum amylase and lipase were within normal range. Cancer Antigen 19-9 (CA 19-19) was not elevated. Random Blood Sugar and Glycated Haemoglobin (HbA1c) were high. Urine showed glycosuria but urinary ketones were negative. Blood and Urine cultures were sterile.Chest X-Ray was normal. Ultrasound abdomen showed chronic calcific pancreatitis with dilated Main Pancreatic Duct (MPD) and tiny intraductal calculi. Common Bile Duct (CBD) was dilated with dilated Inta Hepatic Biliary Radicles. Upper GI endoscopy showed reflux esophagitis with bile reflux. CECT of abdomen showed calcifications in pancreatic head, body and tail with atrophic parenchyma, dilated MPD and multiple intraductal calculi [Table/ Fig-1]. A mass was suspected to be present inferiomedial to the head of the pancreas. Intestinal obstruction was confirmed as Barium meal and follow through showed narrowing in the second part of duodenum. Endoscopy showed pus oozing out from the second part of the duodenum [Table /Fig-2]. Biopsy from the periampullary region of the duodenum showed that there was chronic nonspecific duodenitis with no evidence of invasive malignancy. EUS guided FNAC was done and revealed that the head of pancreas had features of chronic pancreatitis with a few acid fast bacilli. This enabled to arrive at the diagnosis of Tuberculosis of the pancreas.She was started on ATT and Naso Jejeunal (NJ) feeds. She was given Streptomycin, Ethambutol, Isoniazid, Pyrizinamide and Rifampicin in compliance with standardized treatment regimes. She tolerated the treatment well. Repeat LFTs were done and were normal. Her condition progressively improved and she was started on oral feeds. Keywords: Anti tuberculosis therapy, Endoscopic ultrasound, Pancreas ABSTRACTPancreatic Tuberculosis is an uncommon form of extra pulmonary tuberculosis that resembles malignancy of pancreas and serve as a diagnostic challenge for physicians. Conservative management with Anti Tuberculosis Therapy (ATT) will suffice for pancreatic tuberculosis whereas a malignancy may require major surgeries which may lead to significant morbidity. Here, we discuss the case of a female patient who presented with abdominal pain and vomiting and is a known case of chronic calcific pancreatitis. Radiological findings were tha...

Calcified peripancreatic lymph nodes in pancreatic and hepatic tuberculosis mimicking pancreatic malignancy

“…[ 3 ] The morphologies are inconsistent, including irregular, striped, speckled, focal, sand-like calcifications, calcifications forming polycyclic structures, and so on. [ 2 , 5 , 6 , 11 , 13 , 15 , 17 , 18 , 34 , 35 ] Calcifications in pancreatic malignancies have been well described previously, [ 21 , 22 , 28 , 30 ] although there is a lack of summaries of calcifications in pancreatic tuberculosis, partly because of its rarity. Based on these reports, calcifications may be useful, but not specific imaging criteria for the differentiation of pancreatic tuberculosis from malignancy.…”

“…[ 2 , 3 , 5 , 7 , 13 , 14 , 17 – 20 , 34 , 36 – 75 ] Calcifications in pancreatic lesions were observed in 5 cases in limited images provided in articles. [ 5 , 13 , 17 , 20 , 48 ] In 3 of these 5 cases, calcifications in peripancreatic lymph nodes were observed. [ 5 , 17 , 48 ] One case should very likely have calcifications in peripancreatic lymph nodes.…”

“…Because only 1 contrast CT image was provided in the article, it was difficult to distinguish calcified peripancreatic lymph nodes from blood vessels. [ 13 ] In the left 1 case, it was uncertain whether there were peripancreatic lymphadenopathies with calcifications because of lack of images. [ 20 ] We collected all cases of pancreatic tuberculosis with calcifications as we could and collected 6 cases of pancreatic ductal adenocarcinoma with calcifications as control (Table 2 ).…”

Pancreatic Tuberculosis: A Diagnostic Dilemma

“…Other complications include gastric outlet obstruction, portal hypertension, diabetes mellitus, abscess formation, and recurrent acute pancreatitis [6]. Pancreatic TB may also present with peri-pancreatic lymph node enlargement and inflammation [7].…”

A Rare Case of Pancreatic Tuberculosis Diagnosed via Endoscopic Ultrasound-Guided Fine Needle Aspiration and Polymerase Chain Reaction

“…The management of pancreatic TB is mainly a multidrug anti-TB therapy for between 6 and 12 months [12][13]. These patients still need to be followed up closely for subjective and objective response to therapy.…”