Endoscopy 2013; 45(S 02): E317-E318
DOI: 10.1055/s-0033-1344565
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Pancreatic tuberculosis presenting as an unusual head mass

S. S. Rana
1  Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
V. Chaudhary
1  Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
N. Gupta
2  Department of Cytology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
S. Sampath
3  Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
B. R. Mittal
3  Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
D. K. Bhasin
1  Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
› Author Affiliations
Further Information

Corresponding author

S. S. Rana, Dr
Department of Gastroenterology
Post Graduate Institute of Medical Education and Research
Chandigarh – 160012
India   
Fax: +91-172-2744401   

Publication History

Publication Date:
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.

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Fig. 1 Axial contrast-enhanced computed tomography (CECT) in a 28-year-old man with upper abdominal pain and loss of appetite and weight. a Arterial phase, 1.25-mm sections, showing an ill-defined, heterogeneously enhancing lesion in head and body of pancreas encasing the main hepatic artery (arrow). b Corresponding fused positron emission tomography (PET)–computed tomography (CT) image showing intense 18F-fluorodeoxyglucose (FDG) uptake (SUV maximum 15.7) in this lesion. c Venous phase, 1.25-mm sections, showing the mass lesion invading the superior mesenteric vein and the confluence (arrow). d Also seen are enlarged para-aortic and precaval lymph nodes with intense FDG uptake (arrows).
Zoom Image
Fig. 2 Endoscopic ultrasound (EUS) showing a well-defined mass lesion in the head of the pancreas.
Zoom Image
Fig. 3 Photomicrographs showing a epithelioid-cell granulomas with a cluster of benign ductal epithelial cells (black arrow) and a cluster of pancreatic acinar cells (thick arrow) (Papanicolaou, magnification × 20), and b an epithelioid cell granuloma with a cluster of benign ductal epithelial cells (Papanicolaou, magnification × 40).
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Isolated pancreatic tuberculosis is very rare, closely mimicking pancreatic cancer both clinically as well as radiologically [1] [2]. 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 [3]. 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 [4].

Endoscopy_UCTN_Code_CCL_1AZ_2AI


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Competing interests: None


Corresponding author

S. S. Rana, Dr
Department of Gastroenterology
Post Graduate Institute of Medical Education and Research
Chandigarh – 160012
India   
Fax: +91-172-2744401   


Zoom Image
Fig. 1 Axial contrast-enhanced computed tomography (CECT) in a 28-year-old man with upper abdominal pain and loss of appetite and weight. a Arterial phase, 1.25-mm sections, showing an ill-defined, heterogeneously enhancing lesion in head and body of pancreas encasing the main hepatic artery (arrow). b Corresponding fused positron emission tomography (PET)–computed tomography (CT) image showing intense 18F-fluorodeoxyglucose (FDG) uptake (SUV maximum 15.7) in this lesion. c Venous phase, 1.25-mm sections, showing the mass lesion invading the superior mesenteric vein and the confluence (arrow). d Also seen are enlarged para-aortic and precaval lymph nodes with intense FDG uptake (arrows).
Zoom Image
Fig. 2 Endoscopic ultrasound (EUS) showing a well-defined mass lesion in the head of the pancreas.
Zoom Image
Fig. 3 Photomicrographs showing a epithelioid-cell granulomas with a cluster of benign ductal epithelial cells (black arrow) and a cluster of pancreatic acinar cells (thick arrow) (Papanicolaou, magnification × 20), and b an epithelioid cell granuloma with a cluster of benign ductal epithelial cells (Papanicolaou, magnification × 40).
Zoom Image