Isolated Tuberculosis of the Pancreas

Shyam Dang
2
, Muslim Atiq
1
, Michael Saccente
2
, Kevin W Olden
1
, Farshad Aduli
1
1
Division of Gastroenterology and Hepatology and
2
Department of Internal Medicine,
University of Arkansas for Medical Sciences. Little Rock, AR, USA
ABSTRACT
Context Pancreatic tuberculosis is a rare entity. Only a few cases have been reported in the medical literature. We hereby describe a
case of pancreatic tuberculosis in an immunocompromized individual. Case report A fifty-year-old African-American gentleman
with history of HIV non-compliant on anti-retroviral therapy presented with epigastric pain for five weeks duration. CT scan of
abdomen showed large necrotic node on the posterior aspect of the head of pancreas and multiple cystic masses adjacent to the
pancreas. Acid fast bacilli were found on staining of CT guided biopsy of the node. Cultures grew Mycobacterium tuberculosis.
Anti-tubercular therapy was initiated and resulted in gradual resolution of symptoms. Conclusion Pancreatic tuberculosis is rare and
is frequently confused with pancreatic cancer on clinical presentation as well as on imaging studies. Since it is a curable disease,
accurate diagnosis is paramount CT or ultrasound guided biopsy is cornerstone of diagnosis. Endoscopic ultrasound is now
increasingly being used for obtaining tissue for diagnosis. Anti-tubercular therapy is curative in majority of the cases.
INTRODUCTION
Tuberculosis of the pancreas is rare [1]. It is sparsely
reported in medical literature. Majority of the cases
have been reported from tuberculosis endemic regions
of the world. It is often confused with carcinoma of
pancreas or periampullary carcinoma, which are more
common causes of radiologically determined masses in
this anatomical location [1, 2]. Extensive surgical
procedures for this often misdiagnosed medically
treatable condition, is not unheard of, which underlies
the importance of tissue diagnosis in these cases [3].
We hereby report pancreatic tuberculosis in a HIV
positive patient. Through this case, we attempt to
review the clinical presentation, diagnosis and
management of this rare entity.
CASE REPORT
A 50-year-old African-American gentleman with past
medical history of HIV non-compliant on highly active
antiretroviral therapy presented to the Emergency
Department with complaints of progressively
worsening epigastric pain over preceding five weeks.
Pain was described as continuous, dull ache unrelated
to meals. This was not associated with nausea,
vomiting, constipation or obstipation. No recent change
in bowel habits was reported. Patient presented with
low grade fevers, anorexia and weight loss quantified
as 11 kg over the same period. No cough, chest pain or
hemoptysis was reported.
On general physical examination, patient was found to
be cachectic. Oral examination showed presence of
severe oral mucosal thrush. Abdomen was soft and
diffusely tender in epigastrium and left and right upper
quadrants. No hepatosplenomegaly was felt. Bowel
sounds were heard in all four quadrants. Chest was
clear to auscultation. Rest of the systemic examination
revealed no abnormality. On routine investigations,
blood CD4 count was found to be 5 µL-1.
Patient thereafter underwent CT scan of the abdomen
with intravenous and oral contrast which showed a
large necrotic node on the posterior aspect of the head
of pancreas. Large multilobular cystic lesions adjacent
to the pancreas in the porta hepatis and peripancreatic
fat were seen (Figure 1). Enlarged aortocaval lymph
nodes were seen. No bowel obstruction was observed.
No free air or free fluid was noticed. Interventional
radiology assisted with draining the cystic masses
percutaneously under CT guidance. The peripancreatic
mass was biopsied. Biopsy material stained positive for
acid fast bacteria. Acid-fast bacillus cultures grew
Mycobacterium tuberculosis. A diagnosis of pancreatic
and peri-pancreatic tuberculosis was made. Chest X-
ray did not show any evidence of active tuberculosis or
any old healed granulomas.
Received September 27th, 2008 - Accepted November 17th, 2008
Key words HIV; Pancreas; Tuberculosis
Abbreviations HIV: human immunodeficiency virus
Correspondence Farshad Aduli
Division of Gastroenterology, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
Phone: +1-501.686.5175; Fax: +1-501.686.6001
E-mail: faduli@uams.edu
Document URL http://www.joplink.net/prev/200901/13.html

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Patient was started on four drug antitubercular therapy
with isoniazide, pyrazinamide, rifampin and
ethambutol. Highly active antiretroviral therapy was
also initiated. There was gradual resolution of
symptoms. Patient was discharged in a stable condition
and followed-up subsequently as an outpatient.
DISCUSSION
Tuberculosis is a major health problem in developing
countries. Through good part of past three decades
since the advent of HIV, it has posed serious public
health concerns for developed nations as well [4]. It
primarily involves the lungs. It occurs in
extrapulmonary locations in about 15% of the cases
[5]. Pancreas is an organ rarely affected by the
Mycobacteria. Most of the medical literature on this
rare disease is limited to case reports or small case
series. There have been reported incidents in the past
where extensive surgeries have been performed for
high suspicion of periampullary carcinomas which later
turned out to be tuberculosis of the pancreas [3].
Owing to availability of curative pharmacotherapy,
recognition of this disease process is vital.
Tuberculosis of the pancreas presents with nonspecific
symptoms like fever, abdominal pain, weight loss and
anorexia [6, 7]. It has been reported to present as
obstructive jaundice, gastrointestinal bleed, acute or
chronic pancreatitis, pancreatic mass mimicking
malignancy, pancreatic abscess, portal venous
thrombosis causing portal hypertension and even
colonic perforation [8, 9]. It differs from pulmonary
tuberculosis in two distinct ways. First, pancreatic
tuberculosis tends to occur in a younger population
(mean age is about 31 years in India) and occurs due to
ingestion of mycobacteria rather than inhalation [3].
The Mycobacteria gain access to the gastrointestinal
tract where necrotizing granulomas are formed.
Following this, the pathogens enter the lymphatic
system and then invade the organs in the
gastrointestinal tract including the pancreas [10]. The
Mycobacteria may also invade the pancreas by
hematogenous route.
Since it is a treatable disease, diagnosis is vital to
appropriate therapy. History of extra-abdominal
tuberculosis must arouse a strong suspicion. Clinical
symptoms and physical examination add little to the
diagnosis since both are rather non-specific. Imaging
modalities are suggestive but not pathognomic of the
disease. They fail to differentiate between tuberculosis
of pancreas and pancreatic cancer. Ultrasonography
reveals focal hypoechoic lesions or cystic lesions of the
pancreas [11]. Findings on CT scan include hypodense
lesions and irregular borders mostly in the head of the
pancreas, diffuse enlargement of the pancreas or
enlarged peripancreatic lymph nodes [12]. Ring
enhancement or low density areas within enlarged
lymph nodes must raise suspicion of tuberculous lymph
nodes. Definitive diagnosis is based on histological and
bacteriological evidence of disease. Bile cytology or
ERCP has low diagnostic yield estimated around 5%
[3]. Ultrasound or CT guided biopsy or surgical biopsy
is central to definitive diagnosis [1, 11]. In a few cases,
however, diagnosis is made at laparotomy. Endoscopic
ultrasound (EUS) is being increasingly used these days
for imaging and fine needle aspiration of solid or cystic
pancreatic masses [13]. It is now considered the
preferred imaging modality for the diagnosis of
pancreatic masses [14]. The complication rate for the
procedure is rather low (1-2%) [15]. However, it is a
technically difficult procedure with a longer learning
curve compared to CT or ultrasound guided
percutaneous needle biopsies. In a recent randomized
controlled study, comparing EUS-guided biopsy and
CT- or US-guided biopsy for determination of
pancreatic mass etiology, no statistical difference was
found in terms of accuracy [16]. There is no known
negative impact of tumor cell seeding with EUS-guided
FNA of cystic or solid pancreatic masses [17].
Once diagnosis is established, anti tubercular therapy is
administered, which is curative in majority of the cases
[1, 18]. In few patients with billiary obstruction,
surgical or endoscopic therapy may be required [19].
Of note, caution must be exercised in treating
Mycobacterium tuberculosis infection in HIV positive
individuals. Anti tubercular therapy must be started as
early as possible on diagnosis of tuberculosis. Directly
observed therapy is highly recommended. Timing of
initiation of anti-retroviral therapy after starting anti
tubercular therapy is determined by the patient’s
immunologic status (CD4 count). Non nucleoside
reverse transcriptase inhibitor based regimens have
fewer interactions with rifampin and hence are
preferred. Six month duration of therapy is considered
adequate in majority of the patients. However, in some
patients with delayed response to therapy, prolonged
course is recommended [20].
To conclude, a high index of suspicion must be
maintained for pancreatic tuberculosis in immuno-
compromised patients (especially HIV patients) who
present with short duration of non-specific symptoms
of pancreatic disease. Imaging is helpful but tissue
diagnosis is the cornerstone for management. Anti
tubercular therapy is highly effective for therapy.
Conflict of interest The authors have no potential
conflicts of interest
Figure 1. CT scan of the abdomen showing large cystic masses
around the pancreatic head and peripancreatic lymph nodes.

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66
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