Pancreatic tuberculosis presenting as an unusual head mass
05 September 2013 (online)
A 28-year-old man presented with upper abdominal pain accompanied by loss of appetite and weight. The clinical examination was unremarkable. His laboratory investigations revealed serum alkaline phosphatase of 260 IU/l (normal range: 42 – 126 U/L) with normal serum bilirubin. Ultrasound of the abdomen showed a well-defined hypoechoic mass, measuring 3 cm, in the head and body region of the pancreas and a nondilated common bile duct and pancreatic duct. Integrated positron emission tomography (PET)–computed tomography (CT) had similar findings with the mass showing intense 18F-fluorodeoxyglucose (FDG) uptake (standardized uptake value [SUV] value of 15.7) and invading the common hepatic artery as well as the superior mesenteric vein ([Fig. 1]). The peripancreatic and precaval lymph nodes were also enlarged and showed intense FDG uptake. Endoscopic ultrasound (EUS) also had similar findings, with infiltration of the major vessels by the mass ([Fig. 2]). Following EUS-guided fine-needle aspiration from the mass, cytological analysis revealed granulomatous inflammation with negative staining for acid-fast bacilli (AFB) ([Fig. 3]). The patient started four-drug antitubercular therapy (ATT) and showed a marked improvement in symptoms. After 6 weeks of ATT he is asymptomatic with a normal appetite and complete resolution of abdominal pain.
Isolated pancreatic tuberculosis is very rare, closely mimicking pancreatic cancer both clinically as well as radiologically  . It usually presents as a mass lesion in the head of the pancreas and mimics a resectable pancreatic cancer with no vascular involvement; therefore many patients have been diagnosed with pancreatic tuberculosis following Whipple resection . Pancreatic tuberculosis causing local vascular invasion has been very rarely reported and our literature search did not reveal any reports of arterial involvement in pancreatic tuberculosis .
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