Tuberculous Lymphadenitis as a Cause of Obstructive Jaundice: Report of a Case

Abstract

We report a rare case of obstructive jaundice caused by enlarged tuberculous lymph nodes compressing the common bile duct in the retropancreatic region, mimicking pancreatic cancer. A 32-year-old man was admitted to our hospital with a 1-month of history of jaundice. An abdominal computed tomography (CT) scan showed a tumor in the pancreatic head, but an endoscopic retrograde cholangiopancreatogram (ERCP) showed a normal pancreatic duct system. Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy- d-glucose (FDG-PET) revealed a hot spot only in the pancreatic head. Under a presumptive diagnosis of malignancy, a laparotomy was performed and an intraoperative biopsy specimen revealed epithelioid granuloma with caseous necrosis, which led us to suspect tuberculous lymphadenitis. This diagnosis was confirmed by culture, and antituberculous therapy was commenced postoperatively. The patient has not suffered any further episodes of obstructive jaundice. This case report demonstrates that positive FDG-PET results should be interpreted carefully when diagnosing tumors of the pancreatic head.

Tuberculous lymphadenitis as a cause of obstructive jaundice: A case report and literature review

“…TB lymphadenitis can be suspected when a contrast-enhanced CT scan demonstrates low density masses surrounded by an enhancing solid rim [14] , or when ERCP demonstrates a normal pancreatogram with a smooth narrowing of the CBD [18] , as were seen in our patient. FDG-PET scanning has not been shown to be useful in distinguishing TB from pancreatic malignancy, as both conditions have an increased uptake of the FDG metabolite [18] . US or CT-guided percutaneous fine needle aspiration (FNA) of the enlarged lymph nodes may be useful [7] , but is often not definitive [21] .…”

“…Other potential diagnostic methods include obtaining tissue specimens by laparoscopy [17] or endoscopic ultrasound with FNA [27] . Though in practice, the diagnosis is often established at operation [6,7,18,26] or even after surgery by histology [4] or PCR-based assay [2,4,6,8,10] , as was the case in our patient.…”

“…Four mechanisms have been described: TB of the pancreas itself may cause pseudoneoplastic obstructive jaundice [1][2][3][4][5][6][7][8][9][10] ; it may be secondary to TB lymphadenitis causing compression and inflammation of the lymph nodes and the CBD [6,[11][12][13][14][15][16][17][18][19] , as in our case, with caseation of the lymph node causing fistulation into the CBD; biliary TB itself may lead to single or multiple strictures, mimicking cholangiocarcinoma [20][21][22][23][24][25] ; and TB can create a retroperitoneal mass leading to biliary tree obstruction [26] .…”

“…The great benefit of a preoperative diagnosis of TB causing the obstruction is that a more conservative path could be followed, involving removal of the obstructing lymph node alone, followed by anti-TB medications [18] . In our case more elaborate CBD resective surgery was undertaken for presumed malignancy.…”

Peripancreatic Tuberculous Lymphadenitis with Biliary Obstruction Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy

“…Furthermore, FDG PET-CT imaging is widely used to screen for A B malignant tumors and to diagnose metastases by scanning the entire body at once. However, it is often difficult to distinguish tuberculous lymphadenitis from pancreatic malignancy on PET-CT, because both pathologies can result in an increased FDG uptake (32). In cases without characteristic findings of TB, such as in the present case, the QFT test is an important tool in the differential diagnosis.…”