Letter to the Editor: Isolated Pancreatic Tuberculosis: Great Mimicker

To the Editor:

Pancreatic tuberculosis (TB) is a rare and isolated involvement is extremely rare. Pancreatic TB is known to be a great mimicker. The diverse clinical and radiologic picture of this chronic infection may be revealed as pancreatic tumor [1]. Herein, we describe a case of isolated pancreatic TB that presented as pancreatic mucinous cystadenoma.

A 29-year-old male presented to the hospital after a color Doppler ultrasound revealed a pancreatic mass. He reported no abdominal discomfort, fevers, weight loss, cough, or night sweats. The patient denied a history of diabetes mellitus or any infectious disease. Human immunodeficiency virus (HIV)-1 and HIV-2 enzyme-linked immunosorbent assay was negative. Abdominal computed tomography (CT) indicated a low-density nodule measuring approximately 2.2 × 1.7cm seen in the neck-body of the pancreas, and enhanced scanning showed moderate enhancement (Fig. 1A); chest CT was normal. Pancreatic mucinous cystadenoma was considered by ultrasonic contrast. In the arterial phase, no contrast agent perfusion was seen in most areas of the mass, and only a few papillary and grid-like enhancement foci were seen at the edge; in the venous phase, the enhanced part of the mass was more uniformly cleared. Carcinoembryonic antigen, carbohydrate antigen (CA)199, CA125, and CA153 were normal.

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FIG. 1.

(A) Abdominal enhanced computed tomography revealed a low-density nodule in the neck-body of the pancreas. (B) Pathologic examination of the pancreatic mass revealed granulomatous inflammation with caseous necrosis (hematoxylin and eosin staining, × 100).

The patient underwent surgery and histopathologic examination of the pancreatic mass revealed granulomatous inflammation with caseous necrosis (Fig. 1B); pathologic tissue Mycobacterium tuberculosis nucleic acid test was positive. The diagnosis of isolated pancreatic TB was established. Anti-tuberculosis treatment was continued for six months.

Patients with pancreatic TB may be initially asymptomatic and later develop nonspecific complaints. Pancreatic TB has no specific radiologic features. Ultrasonography shows one or more solid hypoechoic masses in the pancreatic parenchyma, or pancreatic heterogeneity or cystic lesions, sometimes showing central liquefaction necrosis, with no specific features of pancreatic TB [2]. Enhanced scan showed pancreatic TB was a mass with irregular margins and peripheral enhancement in the arterial phase, the enhancement was more obvious in the venous phase, and gradually subsided in the delayed phase [2]. These radiographic findings resemble neoplastic cystic lesions or pancreatic inflammation [3]. The diagnosis of pancreatic TB requires histologic/cytologic diagnosis because of the lack of characteristic imaging findings. Biopsy techniques include surgical biopsy (laparoscopic/open), endoscopic ultrasonography (US)-guided biopsy, and CT/US-guided percutaneous biopsy [4].

Although pancreatic TB is still a rare clinical entity, increased awareness of pancreatic TB among clinicians might spare patients from surgical procedures.