Isolated tuberculosis of the pancreas diagnosed with needle aspiration: a case report and review of the literature.

Pancreatic tuberculosis is very rare, especially in immunocompetent patients, and represents a diagnostic challenge. The clinical features in patients with pancreatic tuberculosis are usually non-specific. The radiological features mimic pancreatic malignancy or pancreatitis. We describe a case of pancreatic tuberculosis mimicking carcinoma on Computed tomography scan. Ultrasound guided fine needle aspiration cytology (FNAC) showed caseating granulomatous inflammation. The diagnosis of pancreatic tuberculosis was made and the patient was put on anti-tubercular therapy. Five months later, a repeat CT scan of the abdomen revealed resolution of the pancreatic lesion. We emphasize that tuberculosis should now be included in the differential diagnosis of a pancreatic mass. Diagnostic indicators include the association of a pancreatic mass with fever, the presence of abdominal pain and a cystic pancreatic mass in a younger patient coming from a region where tuberculosis is endemic.     

Pancreatic tuberculosis: an elusive diagnosis

BackgroundPancreatic tuberculosis is a rare disease. Its presenting features are usually vague and non-specific, while the radiological features mimic pancreatic malignancy in many cases and pancreatitis in others. Ultrasound- or CT-guided fine-needle aspiration cytology (FNAC) or biopsy may show caseating granulomatous inflammation but microbiological confirmation may not always be possible. Laparotomy may be required if other investigations prove inconclusive. The response to treatment is good.Case outlinesWe report two young men with pancreatic tuberculosis. The diagnosis was obtained by FNAC in one and laparotomy in the other. Each patient responded to anti-tuberculous chemotherapy and is now asymptomatic.ConclusionTuberculosis should be considered in the differential diagnosis of an obscure pancreatic mass, and the condition is readily curable.     

Tuberculosis of the Pancreas: Report of Three Cases

Three cases of pancreatic tuberculosis are described. The first patient presented with abdominal pain, weight loss, anorexia., vomiting, hepatomegaly, and mass in the head of the pancreas, on computerized tomographic (CT) scan. The second patient presented with low grade fever, anorexia, and weight loss, and was investigated for gallbladder disease. The third patient presented with obstructive jaundice and mass lesion in the head of the pancreas. Two patients underwent laparotomy for suspected pancreatic tumors. The findings of pancreatic disease was incidental during laparotomy in the second patient. The histopathology revealed caseating granuloma in all of them. The first patient responded well to treatment, and the second patient stopped treatment after 2 months and is well. The third patient is being followed. If malignancy can be ruled out, tuberculosis should be considered in relevant geographic areas, and a tissue diagnosis should be made.     

Isolated pancreatic tuberculosis.

We present a case of tuberculosis of the pancreas in a 65 year-old man diagnosed by detection of Mycobacterium tuberculosis DNA in a resection specimen using a highly specific polymerase chain reaction-based assay. Almost all pre-operative and intra-operative findings except for helical computed tomography were highly suggestive of malignant pancreatic tumor. However, the histopathology of the pancreas revealed caseating granulomatous inflammation of possible tuberculous etiology, although special staining and culture of these tissues gave negative results. Only detection of Mycobacterium tuberculosis DNA using the polymerase chain reaction-based assay gave a positive result which allowed antituberculosis treatment to be started. The patient's post-operative recovery has been uneventful without complications. If an early accurate diagnosis can be made in such cases, antituberculosis treatment can be started rapidly.     

The usefulness of colonoscopic biopsy in the diagnosis of intestinal tuberculosis and pattern of concomitant extra-intestinal tuberculosis]

BACKGROUND/AIMS: Intestinal tuberculosis can be difficult to diagnose because it may mimic many other intestinal diseases. The aim of this study was to evaluate the diagnostic yield of colonoscopic biopsy and frequency of concomittent extra-intestinal tuberculosis in intestinal tuberculosis. METHODS: The medical records of 225 consecutive patients with intestinal tuberculosis (81 men, 144 women; mean age 40.6 yrs) were analyzed retrospectively. RESULTS: Histological examination of colonoscopic biopsy specimens revealed granulomas in 163 (72.4%) of the 225 patients. However, caseous necrosis was found in only 25 (11.1%) patients, and acid-fast bacilli (AFB) were noted in 39 (17.3%) of the 225 patients. Mycobacterium tuberculosis was isolated from the culture of biopsy specimens in 52 (29.3%) of 177 patients. Eighty-four patients (37.3%) had concomitant extra-intestinal tuberculosis and 67 (29.8%) showed active pulmonary tuberculosis. Histological examination of the biopsy specimens enabled the diagnosis of intestinal tuberculosis by the presence of either caseating granulomas or AFB in 52 (23.1%) patients. Combination of histological examination and Mycobacterium culture established the diagnosis in 87 (38.7%) patients. Before getting the result of Mycobacterium culture, the diagnosis could be made, by either histological examination or the presence of extra-intestinal tuberculosis in 107 (47.6%) patients. Combination of caseating granulomas, AFB staining, Mycobacterium culture, and the presence of extra-intestinal tuberculosis resulted in the diagnosis in 126 (56.0%) patients. CONCLUSIONS: To increase the diagnostic yield, AFB staining and Mycobacterium culture should be routinely performed on biopsy specimens in addition to routine histological examination for caseating granulomas.     

单纯气管支气管结核60例临床分析

目的：探索单纯气管支气管结核的临床特征及诊断。方法：分析60例单纯气管支气管结核的临床表现，实验室检查，胸部X线及胸部CT表现及纤维支气管镜检查结果。结果：临床表现为咳嗽，喘鸣，发热，胸部X线表现为：肺不张，局限性肺气肿，纤维支气管镜检查结果：黏膜炎性浸润型占43．3％，黏膜溃疡或干酪坏死型占28．3％，肉芽增殖型占16．7％，瘢痕狭窄型11．7％，结论：纤维支气管检镜查是诊断气管支气管结核的最重要的方法。对了解 病情，指导治疗，预测预后有重要意义。     

Antro-duodenal tuberculosis causing gastric outlet obstruction--a rare presentation of a protean disease

Gastroduodenal tuberculosis is a rare location of abdominal tuberculosis. It usually occurs secondary to pulmonary tuberculosis. We report a case of a 63-year-old woman admitted to the referral center for symptoms of upper gastrointestinal obstruction caused by ulcerohypertrophic antroduodenal tuberculosis. The lesion was misdiagnosed as malignancy at endoscopy. Even at surgery, the lesion was considered gastric cancer and imposed an oncologic resection. The diagnosis was established in the presence of giant-cell granulomas with caseating necrosis in the surgical resected specimens. In our case, the rare gastroduodenal location of abdominal tuberculosis occurred as primary tuberculosis, in the absence of other identifiable locations.     

Primary tuberculosis of the pancreas mimicking a pancreatic tumor.

BACKGROUND: Diagnosis of tuberculosis of the pancreas is often missed, and may present to the clinician as a difficult diagnostic problem. METHODS: We report an extremely rare case of a 35-year-old woman who admitted for acute pain in the right upper quadrant, jaundice, fever 38 degrees C and chills. During the last 8 mo, she developed increasing fatigue and a weight loss of approx 10 kg. RESULTS: Computed tomography (CT) of the abdomen showed a mass in the head of the pancreas, and upper gastrointestinal endoscopy revealed a stenosis of the second part of duodenum and a pancreatico-duodenum fistula. Frozen sections by direct trucut needle biopsy raised suspicions of a malignancy, and a Whipple procedure was performed as a radical procedure. The final histopathology revealed a chronic granulomatous lesion with caseating necrosis. Mycobacterium of tuberculosis was detected using the polymerase chain reaction-based assay. CONCLUSION: This unusual case emphasizes that in suspected cases of pancreatic carcinoma with an atypical presentation, an attempt should be made to confirm the diagnosis by CT-guided needle biopsy, or by ultrasound endoscopic fine-needle aspiration.     

Hypophysial tuberculoma with hypopituitarism

In this patient with a caseating pituitary tuberculoma the diagnosis of hypopituitarism was established antemortem by modern tests of pituitary function. Pituitary tuberculoma is rare and may resemble pituitary adenoma. Tuberculoma should be considered in patients with hypopituitarism or enlargement of the sella turcica, or both, who have or have had tuberculosis of any site. Antituberculous therapy should be instituted in such patients, especially when surgery is contemplated.     

COLONIC TUBERCULOSIS MIMICKING A DIMINUTIVE SESSILE POLYP

A 47‐year‐old male patient presented with abdominal discomfort and loose stools. Colonoscopic examination revealed a diminutive sessile polyp on the hepatic flexure. Histological assessment revealed a caseating granuloma with giant epitheloid cell formation consistent with tuberculosis. Early diagnosis and treatment with antitubercular treatment circumvents the morbidity of the disease.     

Primary Tuberculosis of the Pancreas Mimicking a Pancreatic Tumor

Summary Background. Diagnosis of tuberculosis of the pancreas is often missed, and may present to the clinician as a difficult diagnostic problem. Methods. We report an extremely rare case of a 35-year-old woman who admitted for acute pain in the right upper quadrant, jaundice, fever 38°C and chills. During the last 8 mo, she developed increasing fatigue and a weight loss of approx 10 kg. Results. Computed tomography (CT) of the abdomen showed a mass in the head of the pancreas, and upper gastrointestinal endoscopy revealed a stenosis of the second part of duodenum and a pancreatico-duodenum fistula. Frozen sections by direct trucut needle biopsy raised suspicions of a malignancy, and a Whipple procedure was performed as a radical procedure. The final histopathology revealed a chronic granulomatous lesion with caseating necrosis. Mycobacterium of tuberculosis was detected using the polymerase chain reaction-based assay. Conclusion. This unusual case emphasizes that in suspected cases of pancreatic carcinoma with an atypical presentation, an attempt should be made to confirm the diagnosis by CT-guided needle biopsy, or by ultrasound endoscopic fine-needle aspiration.     

克罗恩病和肠结核的组织病理学研究

目的：明确克罗恩病和肠结核的组织病理学特征，找出异同点。方法：利用手术切除的肠结核和克罗恩病理标本，观察其组织病理学特征并比较。结果：克罗恩病的特征为裂隙性溃疡、非干酪样坏死性肉芽肿、肿膜下层增宽；肠结核的特征为干酪样坏死、粘膜下层闭锁，肉芽肿融合，组织切片有许多相似之处，如微肉芽肿，全层炎症等，结论：典型的肠结核和克罗恩病易于鉴别，但二者组织病理学的相似性，给部分病例的鉴别诊断带来困难。     

Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature

Extrapulmonary tuberculosis accounted for 37 percent of all new cases of active tuberculous infection identified at a 522-bed community hospital during an 11-year period. Forty-five foci of extrapulmonary infection were diagnosed in 38 patients. Involvement of the genitourinary system, lymphatic system, and respiratory system, other than the lung, was most common and accounted for 58 percent of all infections. Presenting symptoms were protean and often resulted in long delays between onset of symptoms and eventual diagnosis. Foreign birthplace, prior history of or exposure to tuberculosis, constitutional symptoms, febrile course, and anemia were important findings suggesting the diagnosis. Results of tuberculin skin tests were positive in 31 of 34 patients. Chest radiography demonstrated abnormalities in 25 of 38 patients. Cultures showed growth of Mycobacterium tuberculosis in 27 of 39 affected sites, and caseating granulomas were identified in 31 instances. It is concluded that extrapulmonary tuberculosis remains an important infectious disease problem despite the overall decrease in the national incidence of tuberculosis.     

The pancreas and tuberculosis: a diagnostic challenge.

Pancreatic tuberculosis is often mistaken for malignancy and can pose a diagnostic challenge. A high degree of suspicion is necessary to diagnose this condition which responds well to anti-tuberculosis treatment (ATT). Fine-needle aspiration cytology helps to differentiate malignancy from treatable conditions like tuberculosis. Records of four patients treated for pancreatic tuberculosis between 1997 and 2006 were studied. All patients had a pancreatic mass which was suspected to be malignant at imaging. The diagnosis of tuberculosis was established by FNAC in one case and after laparotomy in one; two had tuberculosis of other systems. All showed good response to ATT which included resolution of the pancreatic mass over mean follow up of 2 years. We suggest that all inoperable masses of the pancreas should be subjected to FNAC to rule out treatable conditions like pancreatic tuberculosis.     

Gastrointestinal tuberculosis: 17 cases collected in 4 hospitals in the northeastern suburb of Paris

Gastrointestinal tuberculosis is a rare form of extrapulmonary tuberculosis and its diagnosis can be difficult. AIMS: To analyze the diagnostic and therapeutic characteristics of gastrointestinal tuberculosis. METHODS: Retrospective study from 17 cases collected in 4 hospitals in Seine Saint-Denis between 1987 and 2002. RESULTS: Seventeen cases and 19 localizations were collected: small intestine (N = 7), ileocecum (N = 6), colon (N = 4) and gastroduodenum (N = 2). Two patients had two localizations. Mean age was 43.9 years. Subjects from immigrant populations (76.5%) were preferentially affected. Twenty-three percent of patients (13 tested) were infected by human immunodeficiency virus. Weight-loss and general weakness (88%), abdominal pain (88%), fever (59%), nausea/vomiting (53%) were the predominant symptoms. The delay in diagnosis was 82 days (range: 7-180) and time before specific treatment 31.6 days (range: 7-90). Histological evidence of caseating granuloma was found in six patients. Mycobacterium tuberculosis was detected in six. Digestive imaging was abnormal in 15 patients. Mesenteric lymph nodes were the most common associated site of tuberculosis (N = 8, 47%). Mean duration of treatment was 8.2 months (range: 6-12). Thirteen patients were cured, three died and one was lost to follow up. CONCLUSION: Gastrointestinal tuberculosis is not an uncommon diagnosis in the north-eastern Parisian area, especially among immigrant populations and immunodeficient patients. The most frequent localizations are the small intestine and ileocecum. Diagnosis can be made by pathology and/or bacteriology on endoscopic and/or surgical biopsy samples.     

Liver involvement in tuberculosis--an autopsy study.

OBJECTIVE: To study the spectrum of histopathological changes in the liver in cases of tuberculosis. MATERIALS & METHODS: This is an autopsy study consisting of 150 adult cases of tuberculosis over a period of 3 years. The diagnosis of tuberculosis was made on the basis of caseating granulomas or acid fast bacilli in the tissue. Cases showing only healed foci of tuberculosis at autopsy were excluded. Clinical details of all cases were obtained from hospital records. At autopsy, gross examination was done meticulously with special emphasis on the liver and extrahepatic biliary tree. Sections from the liver were processed routinely and histopathological findings were analyzed in detail. RESULTS: Patients were between 21 to 60 years of age with a male: female ratio of 2.1:1. Fever was the commonest symptom (62%). On gross examination, at autopsy, pulmonary and extrapulmonary tuberculosis was seen in 79 (52.6%) and 71 (47.4%) cases respectively. Liver involvement was mainly secondary except in one case. The extrahepatic biliary tree was involved in 18 cases, in the form of external compression of the common bile duct by a group of enlarged caseating, matted lymph nodes. The spectrum of histopathological changes of the liver showed epitheloid cell granulomas in 63 (42%), fatty changes in 49 (32.6%), inflammation in 60 (40%), sinusoidal congestion in 48 (32%) and fibrosis in 24 (16%) cases. Of the 63 cases of liver granulomas, 12 (19%) were cases of extensive pulmonary tuberculosis and the remaining were extrapulmonary tuberculosis. Granulomas were caseating in 58.7%, noncaseating in 23.8% and atypical in 17.5% cases. Fatty change ranged from mild to severe. Inflammation was mainly mild to moderate. Stage I and II fibrosis was seen in 13 (8.6%) and stage III and IV in 11 (7.3%) cases. On comparing the granuloma and non-granuloma cases histological features, it was found that fatty changes and inflammation were more with granuloma formation but there was no difference in the degree of fibrosis in the two groups. CONCLUSION: Liver involvement was mainly in the form of secondary tuberculosis. On histopathology, epitheloid cell granulomas were seen in 42% cases, other changes were non-specific. Significant fibrosis was seen in 7.3% cases however the finding of tuberculosis as a cause of significant fibrosis was not consistent.     

Peritoneal tuberculosis in the Fes University Hospital (Morocco). Report of 123 cases

AIMS: Peritoneal tuberculosis is an important public health issue in Morocco. Our aim was to describe the clinical, biological, and therapeutic features of peritoneal tuberculosis treated in a University Hospital in Morocco. PATIENTS AND METHODS: We retrospectively included 123 patients with peritoneal tuberculosis diagnosed at the gastroenterology unit of the Fes University Hospital between January 2001 and August 2003. RESULTS: The mean age was 28 years with a clear female predominance (sex ratio 2.61). Ascites associated with fever were the most frequent signs found in 80.5% of patients. The ascitic fluid was exsudative in 90% of cases and lymphocytic in 88%. The diagnosis was based on laparoscopy or laparotomy with peritoneal biopsy demonstrating caseating granulomatous lesions in 92.4% of patients. Patients were given antituberculous therapy for 6 months, and the outcome was favourable in 90%. CONCLUSION: Peritoneal tuberculosis is very frequent in Morocco, where the diagnosis is based exclusively on peritoneal biopsies obtained during laparoscopy. With an adapted treatment, the course of the disease is favourable in most cases.     

Gastric tuberculosis presenting as linitis plastica: a case report and review of the literature

Gastric tuberculosis is rare and usually presents as an ulcerated lesion or gastric outlet obstruction. Rarer presentations include massive gastrointestinal bleed and gastric perforation. A case of gastric tuberculosis presenting as linitis plastica is reported here. This is the first such case report. The patient was a young woman who presented with non-specific abdominal pain and significant weight loss. The gastric mucosa appeared oedematous and hyperaemic and there was spontaneous oozing of blood on upper gastrointestinal endoscopy. Computed tomography of the abdomen revealed diffuse thickening of the gastric wall. The diagnosis was confirmed by the presence of caseating granulomas with acid fast bacilli in the endoscopic biopsy specimen. The patient showed significant clinical improvement on four-drug anti-tuberculous treatment.     

Caseating hepatic granulomas in Hodgkin's lymphoma

A 68-year-old man presented with recurrent Hodgkin's lymphoma after a 9-year disease-free interval induced by chemotherapy. In addition to histological evidence of recurrent Hodgkin's disease, the liver biopsy specimen showed extensive caseating granulomas. Cultures of bone marrow and liver tissue tested negative for Mycobacterium tuberculosis. No antituberculous treatment was administered, and the patient had an excellent clinical response to additional chemotherapy for lymphoma. Hodgkin's lymphoma should be added to the list of disease entities associated with caseating granulomas in the liver.