Pancreatic Tuberculosis Diagnosed with Endoscopic

Sushil K Ahlawat, Aline Charabaty-Pishvaian, James H Lewis, Nadim G Haddad
Division of Gastroenterology, Department of Medicine, Georgetown University Hospital,
Georgetown University School of Medicine. Washington, DC, USA
ABSTRACT
Context Isolated pancreatic tuberculosis is
rare in the Western world. Its clinical
presentation often mimics pancreatic
malignancy and the diagnosis is usually not
suspected or confirmed prior to laparotomy.
Endoscopic ultrasound guided fine needle
aspiration cytology has proved to be an
excellent tool for the cytological diagnosis of
pancreatic and peripancreatic masses.
However, this technique has not been reported
for diagnosing pancreatic or peripancreatic
tuberculosis.
Case report We describe a 57-year-old South
Asian man with pancreatic tuberculosis who
presented with fever of undetermined origin
and a pancreatic mass on imaging. He was
successfully treated with anti-tuberculosis
regimen following confirmation of his
diagnosis with endoscopic ultrasound guided
fine needle aspiration cytology.
Conclusions Pancreatic tuberculosis should
be suspected in patients having a pancreatic
mass, particularly if patient presents with
fever and lived in, or traveled to, an area of
endemic tuberculosis or exposed to
tuberculosis. When the diagnosis is suspected,
endoscopic ultrasound guided fine needle
aspiration cytology of the pancreatic lesion
can confirm the diagnosis and so avoid an
unnecessary explorative laparotomy or
pancreatic resection.
INTRODUCTION
Tuberculosis presenting as a pancreatic mass
is a rare condition in Western countries
including the United States. Most reported
cases are immigrants to Europe or USA from
countries where tuberculosis is endemic [1].
The frequency of reports of isolated
pancreatic tuberculosis in Western countries
has increased in recent years [2]. We present a
case of pancreatic tuberculosis to highlight
the importance of including tuberculosis in
the differential diagnosis of a pancreatic mass
and to discuss the role of EUS guided FNA as
a preferred technique in diagnosing pancreatic
tuberculosis.
CASE REPORT
A 57-year-old South Asian man presented
with fever of undetermined origin for 6
months associated with anorexia and 8 kg
weight loss. He usually had 1-2 episodes per
week of fever (38-39°C) associated with
chills and profuse sweating occurring in the
evenings and lasting for several hours. He
denied nausea, emesis, abdominal pain,
headache, sore throat, change in bowel habits,
cough, shortness of breath, chest pain or

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urinary dysfunction. His past medical/surgical
history included coronary artery disease status
post angioplasty and coronary artery bypass
graft, chronic anemia for 5 years,
hypercholesterolemia, remote tonsillectomy
and nasal surgery. His medications were folic
acid, iron, clopidogrel, metoprolol, aspirin,
and atorvastatin. He was born in India and
had migrated to the United States nearly 25
years ago. His last visit to India was 15 years
ago. He denied tobacco or alcohol intake or
exposure to person with tuberculosis.
On physical examination, he was noted to be
afebrile and his other vital signs were normal.
No significant findings were found on
examination of his lungs, heart, abdomen,
extremities, skin or nervous system. His
laboratory studies results were as follows:
white blood cell count 6.4/mm³ (reference
range: 3.8-10.8/mm³), hemoglobin 12.8 g/dL
(reference range: 13.2-17.1 g/dL), red blood
cell count 4.84 million/mm³ (reference range:
4.2-5.8 million/mm³), mean corpuscular
volume 82 fL (reference range: 80-100 fL),
platelet count 266,000 mm
-
³ (reference range:
140,000-400,000 mm
-
³). His white blood cell
differential count was normal. His peripheral
smear revealed mild hypochromia. No
malaria or babesia parasites were seen. His
sedimentation rate was 12 mm/h (reference
range: 0-20 mm/h). However, his C-reactive
protein was elevated to 12 mg/L (reference
range: 0-8 mg/L). Other studies including
urine examination, serum chemistries, liver
function tests, blood cultures were non-
revealing. His chest radiograph was normal.
However, several bilateral small ill-defined
pulmonary parenchymal nodules were seen in
lower lobes on CT of his chest and a focal
low attenuation mass was also seen along the
posterior margin of the pancreatic body on CT
of his abdomen. The pancreatic body mass
measured 2.4x1.6 cm and was not associated
with ductal dilatation. The adjacent vessels
were noted to be patent. In addition, a small
celiac region node mass measuring 1.4 x 1. 4
cm was also seen.
EUS also demonstrated a pancreatic body
mass of heterogeneous echotexture and ill-
defined margins (Figure 1a). In addition,
celiac axis adenopathy was also seen (Figure
1b). Using the linear echoendoscope a FNA
cytology was performed with 22-gauge needle
from the pancreatic body mass and the celiac
axis node. The cytology from the celiac node
showed suggestion of granuloma; however,
the cytology from the pancreatic mass was
non-conclusive. Subsequently, patient
underwent a diagnostic laparoscopy because
of the lack of a definitive diagnosis. A
nodular mass was seen within the substance
of the pancreas at the junction of the head and
the body of the pancreas. Biopsy was not
taken because of the deeper nature of the
mass within the pancreatic parenchyma.
Further options were discussed with patient
including explorative laparotomy, repeat FNA
cytology/biopsy. He preferred repeat FNA
cytology/biopsy.
A repeat EUS-guided FNA cytology from the
celiac lymph node showed mixed lymphoid
population, epitheloid granulomas and
Figure 1. Endoscopic ultrasound image showing (a.)
pancreatic mass and (b.) celiac axis region lymph node.

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multinucleated giant cells consistent with
non-necrotizing granulomatous lymphadenitis
(Figure 2). The acid-fast bacilli stain was
negative.
Following his last EUS-FNA, he was started
on empirically anti-tuberculous therapy
consisting of 4 drugs (isoniazid, rifampin,
ethambutol, and pyrazinamide). His fever
resolved within 4 to 6 weeks of starting anti-
tuberculous
therapy.
Subsequently,
polymerase chain reaction for Mycobacterium
tuberculosis was found positive from the
celiac lymph node cell block and his celiac
lymph node culture grew Mycobacterium
tuberculosis that was susceptible to isoniazid,
rifampin, ethambutol, pyrazinamide, and
streptomycin. Patient was treated with 4 drugs
for 2 months and then rifampin and isoniazid
were continued for another 7 months. At the
end of 9 months of anti-tuberculous treatment
he continues to remain afebrile and is
maintaining a normal appetite and weight. He
has no pulmonary or abdominal symptoms.
DISCUSSION
Tuberculosis of the pancreas or of the
peripancreatic lymph nodes is a rare condition
even in countries where tuberculosis is
endemic [3]. One explanation for this low
prevalence is that the pancreas is protected
from being infected by Mycobacterium
tuberculosis probably because of the presence
of pancreatic enzymes, which interfere with
the seeding of Mycobacterium tuberculosis
[3].
We conducted a MEDLINE search for
English language articles from 1966 to 2004
using the MeSH terms “Tuberculosis” and
“Pancreas”. In addition, the bibliographies of
relevant articles were also searched. A total of
116 reports of pancreatic tuberculosis were
identified [4]. Men and women are affected
equally [1, 5], with a mean age of around 40
years. The most likely mechanism of spread is
lymphohematogenous dissemination from an
occult focus in the lungs [3, 6, 7]. The exact
mechanism of pancreatic involvement
by tuberculosis in our patient is unclear,
however, we postulate a hematogenous spread
from reactivation of an occult focus in the
lungs.
The main symptoms at presentation of
pancreatic tuberculosis are pain (81%),
weight loss (55%), fever (36%), recurrent
vomiting (19%) and jaundice (17%) [4]. Most
patients have high sedimentation rate and the
tuberculin test is positive in over 2/3 of cases
[4]. Our patient had a strongly positive
tuberculin test and a normal sedimentation
rate but his C-reactive protein was elevated. A
pancreatic mass mimicking pancreatic
malignancy is seen in over 50% of patients [3,
5, 7]. Most common location of pancreatic
mass has been reported in the head or body as
in our case; however, occasionally isolated
involvement of the pancreatic tail has also
been described [2]. Interestingly abdominal
pain is more frequent at the time of
presentation with pancreatic tuberculosis than
with pancreatic cancer; however, our patient’s
presentation was atypical in a way since he
did not have abdominal pain. The presence of
fever with a pancreatic mass, as in our case,
favors tuberculosis, however, non-Hodgkin’s
lymphoma should also be considered in this
clinical scenario. Other clinical presentations
include obstructive jaundice, pancreatic
abscess, secondary diabetes, massive
gastrointestinal hemorrhage, acute or chronic
pancreatitis, portal or splenic vein thrombosis
[2, 4].
A definitive diagnosis of pancreatic
tuberculosis will prevent unnecessary surgery
Figure 2. Photomicrograph (H&E stain x200) of celiac
axis lymph node cytology showing epitheloid
granuloma.

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and in the setting of suspected malignancy
will change the diagnosis to one of a treatable
infection; however, a definitive diagnosis of
pancreatic tuberculosis is only achieved with
histological
confirmation.
Pancreatic
tuberculosis is usually not suspected prior to
laparotomy. Most patients have been
diagnosed at laparotomy. However, if
tuberculosis is suspected and confirmed then
surgery is not necessary, making FNA
cytology/biopsy a very useful test. However,
only a few cases have been diagnosed by
FNA cytology/biopsy [5, 8, 9, 10]. The
success rate of image guided percutaneous
FNA cytology or biopsy in diagnosing
pancreatic tuberculosis is less than 50% [5, 8,
9, 10]. EUS-FNA cytology/biopsy has proved
to be an excellent tool for the cytological
diagnosis of pancreatic and peripancreatic
masses [11]. A definitive cytological
diagnosis is possible by EUS-FNA in 80% to
95% of cases despite failure of another biopsy
technique [11]. However, to our knowledge
this technique has never been used in
diagnosing pancreatic or peripancreatic
tuberculosis. Ours is the first report of using
EUS-FNA successfully in diagnosing
pancreatic tuberculosis. We preferred EUS-
FNA over percutaneous approach because of
poor success rate as reported in the literature
with percutaneous technique and secondly
because of significant impact of diagnosis on
patient management.
Laparoscopy might prove to be helpful if
tuberculosis is not confirmed by FNA
cytology or core biopsy. Acid fast bacilli are
identified only in 20-40% of cases and culture
results are positive in 77% of cases even
when intraoperative specimen are sent for
direct smear and culture [3]. Caseating
granuloma are seen in 75-100% of cases [4].
Polymerase chain reaction now offers the
possibility of both a more sensitive and more
rapidly available definitive diagnosis
compared to microscopy and culture;
however, the drug susceptibility cannot be
performed from the polymerase chain reaction
specimens and therefore, this test is an
adjunct to standard culture techniques.
Pancreatic tuberculosis should be suspected in
patients having a pancreatic mass or
hypodense lymph nodes in the peripancreatic
region, particularly if patient presents with
fever and is young, not jaundiced, lived in, or
traveled to, an area of endemic tuberculosis,
exposed to tuberculosis, and if investigations
show the patient is human immunodeficiency
virus positive. When the diagnosis is
suspected, a detailed screening for
tuberculosis and EUS-FNA of the pancreatic
lesion can confirm the diagnosis and so avoid
an unnecessary explorative laparotomy or
pancreatic resection.
Received August 16
th
, 2005 - Accepted
September 26
th
, 2005
Keywords
Biopsy,
Fine-Needle;
Endosonography; Pancreas
Correspondence
Nadim G Haddad
3800 Reservoir Road, NW
Georgetown University Hospital
Washington DC
20007 USA
 
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