Pancreatic tuberculosis: a rare cause of pseudoneoplastic obstructive jaundice

Isolated pancreatic tuberculosis is rare, and can mimic pancreatic carcinoma. We report a case of pseudoneoplastic pancreatic tuberculosis revealed by an obstructive jaundice in a 35-Year-old man. Surgical pancreatic histopathology showed a caseating granulomatous inflammation and diagnosis was confirmed by detection of Mycobacterium tuberculosis DNA using specific polymerase chain reaction-based assay (PCR). The patient was successfully treated with quadruple antituberculous therapy. In the context of the diagnostic work-up of a hypodense pancreatic mass, the diagnosis of tuberculosis relies on the presence of pancreatic caseating granulomas, that can be obtained by endosonography-guided biopsy, thus avoiding laparotomy.     

Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma

In this study, two cases of biopsy-proven pancreatic tuberculosis are reported. The patients presented with fever, anorexia, fatigue, abdominal pain and weight loss. A differential diagnosis of fever of unknown origin was conducted. Computed tomography (CT) revealed a cystic mass image in the pancreatic head in one patient, and a hypodense lesion in the pancreatic head in the other. The first patient was diagnosed by a wedge biopsy specimen obtained in the exploratory laparotomy. The other patient was diagnosed by percutaneous fine-needle aspiration biopsy. Both patients were successfully treated with quadruple antituberculous therapy for 12 months. We concluded that especially in young patients who present with a mass in the pancreas, pancreatic tuberculosis should be considered among the differential diagnoses, particularly in developing countries and immunosuppressed individuals.     

Pancreatic tuberculosis with acquired immunodeficiency syndrome: a case report and systematic review

Pancreatic tuberculosis (TB) is a relatively rare disease that can mimic carcinoma, lymphoma, cystic neoplasia, retroperitoneal tumors, pancreatitis or pseudocysts. Here, I report the case of a 31-year-old immigrant Burmese woman who exhibited epigastralgia, fever, weight loss and an epigastric mass. The patient was diagnosed with pancreatic TB and acquired immunodeficiency syndrome, and was treated with antituberculous drugs and percutaneous catheter drainage without a laparotomy. The clinical presentation, radiographic investigation and management of pancreatic TB are summarized in this paper to emphasize the importance of considering this rare disease in the differential diagnosis of pancreatic masses concomitant with human immunodeficiency virus infection. I also emphasize the need for both histopathological and microbiological diagnosis via fine-needle aspiration.     

Pancreatic tuberculosis. Report of two cases

We report two cases of pancreatic tuberculosis. The first patient had abdominal pain, jaundice and weight loss. Ultrasonography and CT scan suggested a pancreatic tumor. The second patient presented with abdominal pain without jaundice while CT scan showed a pancreatic mass. Diagnosis of pancreatic tuberculosis was made at laparotomy in the two cases. The two patients underwent hepatico-jejunostomy. The first one received antituberculous chemotherapy and completely recovered while the second died because of post-operative shock related to sepsis. Tuberculosis must be suspected in the presence of a pancreatic mass in endemic countries or in immunocompromised patients. Needle biopsy may in some cases lead to diagnosis and avoid laparotomy.     

Solitary pancreatic tuberculosis mimicking advanced pancreatic carcinoma

A 40-year-old woman was referred for pancreatic head carcinoma invading the portal vein. The dichotomy between the radiological findings and the general condition of the patient, as well as the laboratory results (no evidence of cholestasis), cast doubt on the diagnosis. There was no history of tuberculosis. The chest radiograph revealed no pathological findings. The anatomic relationships of the lesion entailed a high risk of vascular injury if tissue biopsy were to be done; therefore, diagnostic laparotomy was performed. Biopsy revealed granulomas with caseous necrosis, consistent with tuberculosis. After 6 months of antituberculosis treatment, the lesions had completely resolved. Tuberculosis should be considered in the differential diagnosis of pancreatic masses, particularly in regions where the disease is endemic. The condition usually resembles an advanced pancreatic tumor. Performing a biopsy of inoperable lesions and maintaining a reasonable skepticism in regard to the evaluation of operable lesions (attention to nonexclusive but helpful clues, such as young patient age, history of tuberculosis, absence of jaundice) will lead to the diagnosis in most patients. Diagnostic laparotomy may be required in a small subset of patients. The response to antituberculosis treatment is very favorable. The role of resection (e.g., pancreatoduodenectomy) is very limited.     

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.     

Tuberculous pseudotumors of the liver

A 35 year old man presented with fever, weight loss and adenopathy. The clinical presentation, laboratory studies, liver scan and laparotomy all suggested metastatic carcinoma. Bacteriologic and pathologic studies established a diagnosis of macronodular tuberculosis isolated to the liver. Response to antituberculous drug therapy was rapid. Review of the literature revealed this case to be a rare example of tuberculous pseudotumors of the liver.     

Pancreatic pseudotumor due to peripancreatic tuberculous lymphadenitis

Peripancreatic tuberculous lymphadenitis is a very rare and difficult diagnosis. We report herein a patient with a clinically solitary abdominal tuberculoma. A 68-year-old woman was admitted to our hospital with moderate-level obstructive jaundice due to a mass located between pylorus and head of the pancreas. There were no clinical signs or symptoms of tuberculosis in lungs or abdomen. After the diagnosis of a neoplasm of the pancreas was made, exploratory laparotomy was performed which revealed a conglomerated mass penetrating into the pancreas. Since an exact diagnosis could not be reached on the basis of frozen sections prepared during the operation, a standard Whipple procedure was performed. After the histopathological examination of the resected specimen revealed tuberculous lympadenitis, the patient was given antituberculous medication. The patient recovered well. An abdominal tuberculoma is often mistaken for a malignant neoplasm, and nonsurgical diagnosis and treatment of this entity continues to be a challenge.     

Coexistence of pancreatic carcinoma and pancreatic tuberculosis: case report

Pancreatic tuberculosis (TB) is extremely rare and mimics pancreatic carcinoma both clinically and radiologically. This paper discusses the occurrence of 2 heterogeneous masses located in the head and tail of the pancreas in an adult male. In this patient, laparotomy was performed because of the high suspicion of pancreatic carcinoma. Intraoperative fine needle aspiration biopsy revealed the coexistence of pancreatic carcinoma with pancreatic TB, and a combined resection of the distal pancreas and spleen was successfully performed. Following surgery, the patient received standard chemotherapy for TB. At 7-month follow-up, computed tomography showed resolution of the mass in the pancreatic head. Clinicians must maintain a high index of suspicion for pancreatic TB in patients with pancreatic masses. The coexistence of malignancy and TB should be considered when patients present with multiple pancreatic masses.     

The nodular form of local hepatic tuberculosis. A review

Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. Even less common is the finding of tuberculoma or tuberculous liver abscess without clinical evidence of tuberculosis elsewhere. Since 1950, 21 cases of isolated tuberculoma or tuberculous abscess of the liver have been reported in the world literature. We report an additional two cases, one tuberculoma and one with multiple tuberculous abscesses. The case reports illustrate the difficulty in reaching the correct diagnosis, unsuspected in nearly all cases and most often confused with carcinoma of the liver. The correct diagnosis was made by histology, identification of acid-fast organisms by smear, and by cultures of Mycobacterium tuberculosis, but required laparotomy in 19 of the 23 cases. A greater awareness of this rare clinical entity may prevent needless surgical intervention since the vast majority of patients respond well to antituberculous chemotherapy.     

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.     

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.     

Abdominal tuberculosis in children. Report of 10 cases

BACKGROUND: Abdominal tuberculosis is a rare location of this infection with a lot of diagnostic difficulties. The aim of this study was to review our experience of pediatric abdominal tuberculosis with that of the literature data. PATIENTS AND METHODS: A retrospective study was conducted over a 7-year period; 10 cases of abdominal tuberculosis in children were reviewed (6 girls and 4 boys, mean age: 11 years, extremes 4-14). Eight patients enrolled in this study satisfied the following criteria: a positive culture for mycobacterium tuberculosis on samples of ascites fluid, sputum, urine, abscess puncture and/or caseating granulomas on histologic examination of biopsies obtained by endoscopy, percutaneous aspiration or needle biopsy or exploratory laparotomy. Two other patients (patients No 1 & 5) had a favorable response within 10 weeks of antituberculous therapy. RESULTS: We observed 8 cases of peritoneal tuberculosis and 2 cases of intestinal tuberculosis. Extra-abdominal tuberculosis was found in 4 of those patients. Two patients had a contact with a tuberculosis positive individual. Nine children had BCG immunization. The main clinical features were abdominal distension (6 cases) and abdominal pain (6 cases). Abdominal ultrasonography visualized mesenteric lymphadenopathies (6 cases), an abdominal mass (5 cases), free (1 case) and localized ascites (1 case). Barium enema and small bowell series showed small bowel stenosis (1 case) and ileal ulcerations (1 case). Exploratory laparotomy, performed in 3 patients, showed whitish granulations and peritoneal abscesses with caseous necrosis on histology. Quadruple therapy with tuberculostatic agents was prescribed in all patients, associating isoniazid, rifampicin, pyrazinamide combined at the start of the treatment with streptomycin (7 cases) and ethambutol (3 cases). Short term outcome was favorable with no deaths. The long term outcome was complicated by persistent ascites (1 case) and the development of portal hypertension (1 case). CONCLUSION: Abdominal tuberculosis remains a rare localization with a lot of diagnostic difficulties.     

Tuberculosis of the bile duct: a rare cause of obstructive jaundice.

Tuberculosis of the bile duct is extremely rare. Patients with this condition usually present with a protracted illness and obstructive jaundice, which may be confused with hepatobiliary malignancies. A retrospective review of hospital records of patients who presented with tuberculosis of the bile duct between January 1986 and December 1996 was undertaken, and data were obtained concerning clinical presentation, investigations, treatment, and follow-up. Four patients (one man and three women) with a mean age of 44.8 years had tuberculosis of the bile duct. Diagnostic imaging techniques showed bile duct dilation in all four patients. Endoscopic retrograde cholangiopancreatography (ERCP) showed a stricture in the proximal common bile duct (CBD) in one patient, a stricture in the distal CBD in one patient, a stricture in the common hepatic duct (CHD) in one patient, and multiple strictures in the CHD and left intrahepatic duct in one patient. Bile cytology and fine-needle aspiration identified correctly the diagnosis in each patient. Two patients underwent laparotomy with the initial suspicion of cholangiocarcinoma; the correct diagnosis was made based on frozen sections taken intraoperatively. One patient was treated with endoscopic stenting and three patients underwent laparotomy for bile duct obstruction. All patients received antituberculous therapy. There were no deaths; all patients remained healthy at a mean follow-up of 36.5 months. It is important to obtain a tissue diagnosis in all patients with obstructive jaundice to avoid missing this rare but curable disease. The treatment of tuberculosis of the bile duct involves relief of the bile duct obstruction and antituberculous therapy.     

Abdominal tuberculosis--experience of a University hospital in Oman

OBJECTIVE: To determine the clinical presentation and assess the usefulness of various diagnostic modalities and outcome of treatment of abdominal tuberculosis (TB). Materials and methods: The files of patients admitted to Sultan Qaboos University Hospital (SQUH) with a diagnosis of abdominal TB from January 91 to December 99 were studied retrospectively and data abstracted. RESULTS: Eighteen patients were diagnosed during this period, of which ten were males. The median age was 27 years (range 5-65). The common symptoms were fever, weight loss, anorexia, and abdominal pain. Abdominal signs were less frequent and included hepatomegaly and ascites. Eight patients had co-existent immunocompromised disorders; two of these had active pulmonary TB. Diagnostic investigations included gastrointestinal contrast studies in two, ultrasound (US) guided fine needle aspiration cytology (FNAC) in nine, and laparoscopy and/or laparotomy in seven. All patients underwent antituberculous therapy for 9-12 months, in addition to the treatment of associated disorders. The response to antituberculous therapy was good except in one patient with HIV. Four patients died from associated primary disorders. CONCLUSIONS: The clinical presentation was non-specific and nearly half of the patients had associated immunocompromised disorders; thus a high index of clinical suspicion is required. US guided FNAC and selective laparoscopy were the most useful diagnostic modalities. Antituberculous therapy was effective.     

Three elderly cases of renal cell carcinoma with pancreatic metastasis

Three elderly patients, (an 80-year-old female, 78-year-old female and 78-year-old male) suffering from renal cell carcinoma with pancreatic metastasis were reported. In all cases, renal cell carcinoma had been diagnosed previously. Pancreatic tumors were revealed by computed tomography and ultrasonic study during subsequent admission in all cases. In the first case, laparotomy and histological examination proved that pancreatic tumor was metastatic from renal cell carcinoma. In the other cases, according to their clinical course and other laboratory data, we considered the pancreatic tumors to be metastatics from renal cell carcinoma though histological diagnosis was not obtained.     

Intrapancreatic accessory spleen. A rare cause of a pancreatic mass.

CONCLUSION: The clinical significance of intrapancreatic accessory spleens resides in the mimicry of pancreatic cancer. Radionuclide tests (Octreotide scan and Tc99m sulfur colloid scan) should be undertaken to distinguish these lesions from neuroendocrine tumors, hypervascular metastases and pancreatic carcinoma. If the tests are equivocal, diagnostic laparotomy or laparoscopy is recommended. BACKGROUND: Despite its relatively common occurrence, intrapancreatic ectopic splenic tissue is rarely detected owing to its asymptomatic nature. METHODS: We report a case of a clinically asymptomatic patient in which abdominal computed tomography (CT) scans revealed a mass of 1.5 cm in diameter in the distal pancreas. The tumor markers CA 19-9 and carcinoembryonic antigen (CEA) were slightly elevated, and pancreatic neoplasm was suspected. RESULTS: Left pancreatic resection and splenectomy were performed. The removed specimen disclosed the presence of an accessory spleen within the pancreatic tail.     

Gastric tuberculosis

Tuberculosis of the stomach is an extremely rare manifestation of Mycobacterium tuberculosis infection and mimics gastric carcinoma in its presentation. Most of our knowledge about this rare disease comes from case reports and there are only a few case series published on this disease and thus the majority of the part remains uncovered. Diagnosis is made commonly only after a major surgery. Endoscopy and guided biopsy are the diagnostic modality of choice. Surgery is indicated in cases which present with complications. Patients respond well to antituberculous therapy. The authors encountered 4 cases of gastric tuberculosis over 5 years. This study summarises the available literature and gives comprehensive update on this rare disease.     

Intrapancreatic accessory spleen

Summary Conclusion: The clinical significance of intrapancreatic accessory spleens resides in the mimicry of pancreatic cancer. Radionuclide tests (Octreotide scan and Tc99m sulfur colloid scan) should be undertaken to distinguish these lesions from neuroendocrine tumors, hypervascular metastases and pancreatic carcinoma. If the tests are equivocal, diagnostic laparotomy or laparoscopy is recommended. Background: Despite its relatively common occurrence, intrapancreatic ectopic splenic tissue is rarely deted owing to its asymptomatic nature. Methods: We report a case of a clinically asymptomatic patient in which abdominal computed tomography (CT) scans revealed a mass of 1.5 cm in diameter in the distal pancreas. The tumor markers CA 19-9 and carcinomebryonic antigen (CEA) were slightly elevated, and pancreatic neoplasm was suspected. Results: Left pancreatic resection and splenectomy were performed. The removed specimen disclosed the presence of an accessory spleen within the pancreatic tail.     

Peritoneal tuberculosis with negative polymerase chain reaction results: report of two cases

Peritoneal tuberculosis is rarely observed in European countries. We report on peritoneal tuberculosis in two female immigrants from Somalia and Columbia who presented with diffuse abdominal pain, fever, weight loss and exudative, lymphocytic ascites. Laboratory investigations showed an increase in C-reactive protein and carcinoma antigen 125 serum levels. Nodular peritoneal lesions and adhesions were detected by ultrasound and computed tomography. In both patients, peritoneal biopsy from laparoscopy revealed epitheloid granulomas with central necrosis and multinucleate giant cells. Microscopy and PCR analysis were, however, negative for Mycobacterium tuberculosis in both patients. Despite repeated testing, ascites culture became positive for M. tuberculosis in only one patient. Shortly after starting antituberculous drug treatment, both patients improved, ascitic fluid disappeared and C-reactive protein and carcinoma antigen 125 serum levels returned to normal. Even in Western countries, peritoneal tuberculosis should be considered in any febrile patient with abdominal signs and symptoms, particularly if ascites is present. Empirical antituberculous treatment is justified in patients with clinical and histological features highly suggestive of peritoneal tuberculosis, even in cases with negative results from microscopy, culture and PCR analysis.