The pancreas and tuberculosis: A diagnostic challenge
Abstract
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.
... 4,5 Modern imaging techniques as computed Clinical presentation of pancreatic TB closely mimics that of a pancreatic carcinoma and hence poses a diagnostic dilemma. 6,7 Pancreas enjoys high degree of protection from TB owing to the pancreatic enzymes which interfere with seeding of pathogenic bacilli. 8,9 The theories proposed in the TB involvement of the pancreas are haematogenous spread from a pulmonary source and direct lymphatic spread from adjacent peripancreatic lymph nodes. ...
... Clinical presentation and laboratory evaluation usually fail to differentiate pancreatic TB from malignancy often subjecting the patient to avoidable radical surgery. [7][8][9] Diagnosis is established by histopathology and direct identification of the organism from the tissue by microbiological met hods. Ho wever, diagnosis can still be difficult as bacteriological confirmation is possible only in 57% cases of extra pulmonary TB. 8 Diagnostic tests based on polymerase chain reaction (PCR) in the tissue samples have been proposed to be highly specific even when tissue samples are negative for bacteriological studies. ...
... Various lesions described on CT of abdomen are focal hypodense masses, pancreatic no dules, multiloculated, cystic lesions, low attenuation peripancreatic and periportal adenopathies with peripheral rim enhancement. 6,7,9 In acquired immunodeficiency syndrome (AIDS) patients diffusely hypoechoic enlarged gland and cystic mass lesion have been described on abdominal utorasonography. 7 ...
Tuberculosis of pancreas in an immunocompetent individual is rare even in endemic regions. We report here one
such case where in a 53-year-old man presented with jaundice, weight loss and cervical lymphadenopathy. Base line
liver functions were deranged. Imaging studies of abdomen and chest revealed a pancreatic mass and miliary filtrates.
Fine needle aspiration cytology of cervical lymph nodes was suggestive of tuberculosis. In view of deranged baseline
liver functions the patient was started on a modified daily self-supervised antituberculosis treatment and oral
corticosteroid treatment made an uneventful recovery with complete resolution of mass lesion.
... 31 Therefore the approach to diagnosis of pancreatic tuberculosis should include an effort to make a preoperative diagnosis of the pancreatic masses prior to surgical intervention without causing a considerable delay in diagnosis and management. 58 This should be done without delaying prompt surgical excision of resectable pancreatic cancer which is the major differential diagnosis for pancreatic masses. 59 ...
Pancreatic tuberculosis is very rare, but recently, there has been a spurt in the number of reports on pancreatic involvement by tuberculosis. It closely mimics pancreatic cancer, and before the advent of better imaging modalities it was often detected as a histological surprise in patients resected for a presumed pancreatic malignancy. The usual presentation involves abdominal pain, loss of appetite and weight, jaundice which can be associated with cholestasis, fever and night sweats, palpable abdominal lump, and peripheral lymphadenopathy. Computed tomography (CT) of the abdomen is an important tool for evaluation of patients with pancreatic tuberculosis. This CT imaging yields valuable information about the size and nature of tubercular lesions along with the presence of as-cites and lymphadenopathy. However, there are no distinctive features on CT that distinguish it from pancreatic carcinoma. Endoscopic ultrasound provides high resolution images of the pancreatic lesions as well as an opportunity to sample these lesions for cytological confirmation. The presence of granulomas is the most common finding on histological/cytological examination with the presence of acid fast bacilli being observed only in minority of patients. As there are no randomized or comparative studies on treatment of pancreatic tuberculosis it is usually treated like other forms of tuberculosis. Excellent cure rates are reported with standard anti tubercular therapy given for 6–12 months.
Pancreatic tuberculosis (TB) is a relatively rare disease that can mimic carcinoma, metastatic carcinoma, cystic neoplasia, retroperitoneal tumors, pancreatic abscess, pancreatic pseudocyst or pancreatitis. In general the correct diagnosis is not established before surgery unless there are detectable foci of TB somewhere else or a relevant clinical history. Review of the clinical presentations, radiographic investigations, laboratory findings, criteria and clues for diagnosis as well as management of pancreatic TB were summarized to emphasize the significance of this rare disease in the differential diagnosis of a pancreatic mass and the necessity of pathological and microbiological diagnosis by fine-needle aspiration.
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Problems in the management of abdominal tuberculosis are discussed with reference to 300 surgically verified cases. The protean clinical manifestations depend on the site and extent of the disease, and its complications. Operation was resorted to for complications when diagnosis was in doubt and when intrinsic intestinal disease was proved. Surgery was preceded by antituberculous drugs whenever possible. At operation, the disease was found to involve the alimentary canal in 196 cases; in the remaining 104, only the lymph nodes and/or the peritoneum were affected. Intestinal resection was carried out in 100 cases. Emergency surgery carries a high mortality (18/76) because of toxemia, hypoproteinemia, anemia, etc. Positive histology was obtained in 229 cases. One hundred and seventy-nine cases showed evidence of caseation. Caseation and peritoneal tubercles (103 cases) differentiate intestinal tuberculosis from Crohn's disease. Despite considerable progress made in therapy and prophylaxis during the last quarter of the century, tuberculosis of various sites continues to be a major health hazard in India. The precise prevalence of Koch's disease of the abdomen has not been determined due to lack of a survey in random samples of population. This common malady, however, with its protean profiles and varied complications continues to challenge the diagnostic acumen and therapeutic skill of clinicians practicing various discplines of medicine.
We report three cases of biopsy proven pancreatic tuberculosis. The patients presented with abdominal pain and intermittent fever. Ultrasound and computed tomography revealed a diffusely enlarged pancreas with focal hypoechoic/hypodense lesions in all three patients. In addition, one patient had a large pancreatic cyst with internal echoes. Associated findings included peripancreatic and mesenteric lymph nodes, bowel wall thickening of ileocecal junction, focal hepatic or splenic lesions, splenic vein thrombosis, and ascites. Pancreatic tuberculosis should be considered in the differential diagnosis of focal pancreatic lesions, especially if associated with ancillary findings such as enlarged hypodense nodes in the peripancreatic region or in the mesentery in patients presenting with longstanding fever and abdominal pain.
Tuberculosis affecting the pancreas is rare. Its occurrence may pose a diagnostic problem in differentiating it from carcinoma of the pancreas. Two cases of tuberculosis affecting the pancreas are reported, illustrating the value of fine needle aspiration in such a situation. The response of the disease to antituberculous drugs was slow, but sure.
Pancreatic tuberculosis is usually unsuspected as it can present in various forms. Though an uncommon disease, once diagnosed it is potentially curable.
Retrospective review of the records of 9 patients with histologically proven tuberculosis of the pancreas.
In none of the 9 patients was a preoperative diagnosis of tuberculosis possible. The diagnoses considered included: pancreatic cancer (n = 5); acute pseudocyst (n = 1); pancreatic abscess (n = 1); chronic pancreatitis with pancreatic head mass (n = 1), and carcinoma of the colon causing massive lower gastrointestinal bleeding (n = 1). All the patients underwent surgery. The diagnosis of tuberculosis was confirmed by histopathological examination of biopsy specimens obtained at the time of laparotomy. One patient died, the remaining patients received antitubercular therapy and are doing well at a median follow-up period of 26 months.
In view of the nonspecific and variable clinical presentation and atypical radiological signs, a clinical diagnosis of pancreatic tuberculosis is usually not possible. Therefore there should be a high index of suspicion for this disease in young patients residing in endemic areas. Our experience highlights the importance of performing biopsy in apparently inoperable pancreatic mass lesions.