Pancreatic tuberculosis : a case report

Introduction Though abdominal tuberculosis is common in developing and endemic countries, pancreatic tuberculosis is rare. Pancreatic tuberculosis can present with non-specific signs and symptoms or with features of pancreatitis/neoplasm. Computerised tomography (CT) of abdomen can suggest pancreatic tuberculosis, but cytological/histological confirmation is required to establish the diagnosis. Ultrasound/CT-guided fine-needle aspiration biopsy can help in achieving the diagnosis. This paper discusses a case report of pancreatic tuberculosis. Case report We present a case of a 22-year-old young girl, who was admitted to the surgical outpatient department, with abdominal pain and night sweats for three months. The pain was located in the upper abdomen, with radiation to the back. Examination revealed tenderness in the epigastric region. Conclusion The majority of patients respond to anti-tubercular treatment and prognosis is good. Introduction Pancreatic tuberculosis (TB) is rare. It should be considered in the differential diagnosis of focal pancreatic lesions, in people, in developing countries and those with constitutional symptoms. Diagnosis of pancreatic TB has always been a challenge to the clinicians, but improvement in radiological investigations and image-guided interventions have helped in the diagnosis and prevention of unnecessary laparotomy1. We are present a rare case of isolated pancreatic TB in a 22-year-old girl. Case Report We present a case of a 22-yearold young girl, who was admitted to the surgical outpatient department (OPD), with abdominal pain and night sweats for three months. The pain was located in the upper abdomen with radiation to the back. History of weight and appetite loss was present (weight loss was undocumented, but patient provided a history of loosening of clothes). There was no history of alcoholism, gall bladder disease and pulmonary TB. There was no history of TB in the family. Examination revealed tenderness in the epigastric region. Investigations showed a white blood cell count of 8,000 per mm3 (polymorphonuclear leukocyte [PMN] 73%, lymphocytes 24%); haemoglobin (Hb) was 11 gm/100 ml; elevated erythrocyte sedimentation rate was found to be 60 (reference range: 0–20 mm); liver function tests were found to be normal and serum amylase was 320 IU/L (reference range: 0–160 IU/L). Mantoux test was found to be negative. A chest Su rg er y * Corresponding author Email: umeshjethwani89@gmail.com Vardhman Mahaveer Medical College and Safdarjung Hospital, New Delhi, India Figures 1 & 2: Showingthe bulky head and body of the pancreas, with heterogeneous areas of non-enhancement suggestive of necrosis and peripancreatic fat stranding and peripancreatic lymphadenopathy. Figures 3 & 4: Repeat CECT of the abdomen performed after six months showed gradual radiological resolution of the lesion. Case report Page 2 of 3 Co m pe ti n g in te re st s: n on e de cl ar ed . C on fl i ct o f i nt er es ts : n on e de cl ar ed . A ll au th or s co nt rib ut ed to th e co nc ep ti o n, d es ig n, a nd p re pa ra ti o n of th e m an us cr ip t, a s w el l a s re ad a nd a pp ro ve d th e fi n al m an us cr ip t. A ll au th or s ab id e by th e A ss oc ia ti o n fo r M ed ic al E th ic s (A M E) e th ic al ru le s of d is cl os ur e. Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Jethwani U, Singh G, Mohil RS, Kandwal V, Chouhan J, Saroha R, et al. Pancreatic tuberculosis: a Case report. OA Case Reports 2013 Jun 05;2(5):41. radiograph scan did not reveal any abnormality. Ultrasound scan of the abdomen showed a bulky pancreas. Contrast-enhanced computerised tomography (CECT) of the abdomen demonstrated the bulky head and body of the pancreas, with heterogeneous areas of non-enhancement suggestive of necrosis and peripancreatic fat stranding and peripancreatic lymphadenopathy (Figures 1 and 2). CT-guided fine-needle aspiration biopsy (FNAB) was performed, which revealed caseous necrosis and acid-fast bacilli was not detected. The culture demonstrated the growth of Mycobacterium tuberculosis. The patient was treated with anti-TB chemotherapy, which included four drugs for two months as follows: Cap Rifampicin 450 mg (R), Tab Isoniazid (H) 300 mg, Tab Ethambutol (E) 800 mg and Tab Pyrizinamide (Z) 1500mg and two drugs for four months (HR). The patient was asymptomatic after completing two months of therapy. In the follow-up, the patient showed gradual gain in weight (8 kg in six months), decrease in erythrocyte sedimentation rate (ESR) and repeat CECT of the abdomen performed after six months showed gradual radiological resolution of the lesion (Figures 3 and 4).


Introduction
Pancreatic tuberculosis (TB) is rare.It should be considered in the differential diagnosis of focal pancreatic lesions, in people, in developing countries and those with constitutional symptoms.Diagnosis of pancreatic TB has always been a challenge to the clinicians, but improvement in radiological investi-gations and image-guided interventions have helped in the diagnosis and prevention of unnecessary laparotomy 1 .We are present a rare case of isolated pancreatic TB in a 22-year-old girl.

Case Report
We present a case of a 22-yearold young girl, who was admitted to the surgical outpatient department (OPD), with abdominal pain and night sweats for three months.The pain was located in the upper abdomen with radiation to the back.History of weight and appetite loss was present (weight loss was undocumented, but patient provided a history of loosening of clothes).There was no history of alcoholism, gall bladder disease and pulmonary TB.There was no history of TB in the family.Examination revealed tenderness in the epigastric region.
Investigations showed a white blood cell count of 8,000 per mm 3 (polymorphonuclear leukocyte [PMN] 73%, lymphocytes 24%); haemoglobin (Hb) was 11 gm/100 ml; elevated erythrocyte sedimentation rate was found to be 60 (reference range: 0-20 mm); liver function tests were found to be normal and serum amylase was 320 IU/L (reference range: 0-160 IU/L).Mantoux test was found to be negative.radiograph scan did not reveal any abnormality.Ultrasound scan of the abdomen showed a bulky pancreas.Contrast-enhanced computerised tomography (CECT) of the abdomen demonstrated the bulky head and body of the pancreas, with heterogeneous areas of non-enhancement suggestive of necrosis and peripancreatic fat stranding and peripancreatic lymphadenopathy (Figures 1   and 2).CT-guided fine-needle aspiration biopsy (FNAB) was performed, which revealed caseous necrosis and acid-fast bacilli was not detected.The culture demonstrated the growth of Mycobacterium tuberculosis.The patient was treated with anti-TB chemotherapy, which included four drugs for two months as follows: Cap Rifampicin 450 mg (R), Tab Isoniazid (H) 300 mg, Tab Ethambutol (E) 800 mg and Tab Pyrizinamide (Z) 1500mg and two drugs for four months (HR).The patient was asymptomatic after completing two months of therapy.In the follow-up, the patient showed gradual gain in weight (8 kg in six months), decrease in erythrocyte sedimentation rate (ESR) and repeat CECT of the abdomen performed after six months showed gradual radiological resolution of the lesion (Figures 3 and 4).

Discussion
Isolated TB of the pancreas is rare even in countries with a high prevalence of TB 2 .Bhansali et al. reported 300 abdominal TB cases over a 12-year-period, but found no pancreatic TB case 3 .The pancreas is biologically resistant to infection by Mycobacterium tuberculosis.Possible mechanisms of involvement of the pancreas are as follows [4][5][6] : • The first possible way is that tubercle bacilli reach the pancreas through haematogenous dissemination from an occult lesion in the lungs or abdomen.• The second way is that the route by direct spread from contiguous lymph nodes may be responsible for most of the cases with isolated pancreatic TB. • The third possible way is that dormant bacilli in an old tubercular lesion can re-activate in an immunosuppressive state.
The prevalence of pancreatic TB is similar in males and females with a mean age of 40 years 7,8 .Pancreatic TB can present with symptoms of epigastric pain, fever, anorexia, weight loss, jaundice and pancreatic mass 9 .These features are nonspecific.The CT findings include hypo-dense lesions and irregular borders, usually in the head of the pancreas, in diffused enlargement of the pancreas or in enlarged peripancreatic lymph nodes.The presence of hypo-dense lymph nodes, with rim enhancement in the peripancreatic  region, ascites and/or mural thickening affecting the ileocecal region, may suggest the possibility of TB 1,10 .These features are also non-specific and can resemble pancreatic carcinoma, pancreatitis and lymphoma.Therefore, to establish the diagnosis of pancreatic TB, histological, cytological as well as bacteriological confirmations are necessary.Ultrasound-guided (USG) or CT-guided FNAB has been used to confirm the diagnosis and to prevent unnecessary laparotomies [11][12][13] .In this case, the diagnosis was made by CT-guided FNAB.There are no specific guidelines for management because of the rarity of the disease.The majority of patients respond to 6-12 months of anti-tubercular chemotherapy.The patient in this case report also responded well to the anti-tubercular chemotherapy.Follow-up of the patient included monitoring patient's weight, ESR test and USG/CT scan to look for the resolution of lesions of the pancreas.The patient also re-gained her weight and CT scan showed evidence of resolution of the lesion.Similar cases have been reported in past which are described in table2.

Conclusion
Pancreatic TB should be considered in differential diagnosis of patients presented with pancreatic masses, especially in areas where TB is endemic.High index of suspicion, CT/ USG FNAB is extremely important to make the diagnosis of pancreatic TB.The majority of patients respond well to anti-tubercular chemotherapy and prognosis is good.

Figures 1 & 2 :
Figures 1 & 2:Showing-the bulky head and body of the pancreas, with heterogeneous areas of non-enhancement suggestive of necrosis and peripancreatic fat stranding and peripancreatic lymphadenopathy.

Figures 3 & 4 :
Figures 3 & 4:Repeat CECT of the abdomen performed after six months showed gradual radiological resolution of the lesion.