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Year : 2005  |  Volume : 15  |  Issue : 1  |  Page : 29-30
Tuberculosis of pancreas: A case report


Nizam's Institute of Medical Sciences Panjagutta: Hyderabad (AP), India

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Keywords: Rhomboencephalosynapsis, Cerebellum, congenital anomaly

How to cite this article:
Uma K, Reddy J J, Kumar A, Prayag A. Tuberculosis of pancreas: A case report. Indian J Radiol Imaging 2005;15:29-30

How to cite this URL:
Uma K, Reddy J J, Kumar A, Prayag A. Tuberculosis of pancreas: A case report. Indian J Radiol Imaging [serial online] 2005 [cited 2019 Sep 19];15:29-30. Available from: http://www.ijri.org/text.asp?2005/15/1/29/28280

   Introduction Top


Tuberculosis is an extremely common disease in the developing countries, though its incidence is on the rise in western world too. Tuberculosis of the digestive system can involve any part from esophagus to anus, including peritoneum, mesenteric lymphnodes, liver or spleen. Atypical form of the disease is commonly seen with immuno- compromised patients' [1]. Pancreatic tuberculosis is considered as a very rare clinical entity, although in postmortem studies pancreatic involvement was seen in 4.7-14% deaths from miliary tuberculosis. Increased incidence of this entity is related now to frequency of abdominal tuberculosis in immuno-compromised patient and the improvement in imaging methods of pancreas [2].


   Case report Top


55year old alcoholic male presented with 2 months history of abdominal discomfort, diabetes, obstructive jaundice and features of cholestasis. There was significant weight loss with loss of appetite. On clinical examination, he was found to have pallor, icterus, cervical adenopathy and hepatosplenomegaly. Laboratory investigations revealed raised erythrocyte sedimentation rate (60mm in 1st hr, normal range 3-6mm 1st hr) and elevated serum alkaline phosphatase which was three times elevated (normal range - 80 to140U/L) Serum bilirubins both total and conjugated were also elevated. Chest radiograph [Figure - 1] revealed bilateral apical infiltrates.Abdominal Ultrasonography [Figure - 2] showed mixed echogenic mass lesion in the region of pancreatic head with central hypo to anechoic foci suggestive of necrosis. Pancreatic duct was normal. Minimal intrahepatic biliary radicular dilatation was noted. Lymphadenopathy was noted in the peripancreatic, mesenteric and para-aortic regions. Contrast enhanced computed tomography (CECT) of abdomen with oral and intravenous contrast administration, revealed diffusely enlarged pancreas with obliteration of peripancreatic fat planes and heterogeneously enhancing focal lesion involving the head of the pancreas measuring 3.5x4.2cm with central necrosis [Figure - 3].Pancreatic duct was normal. Multiple enlarged retroperitoneal, peripancreatic and mesenteric group of lymph nodes were noted [Figure - 4]. FNAC and biopsy from the cervical node showed features of Granulomatous infection, followed by CT guided fine needle aspiration cytology from the pancreatic lesion was performed with prior informed consent [Figure - 5]. Pus aspirated from the necrotic area within the gland and sent for Acid Fast Bacillus staining was negative. Cytopathology from pancreatic mass showed clusters of epitheloid cells in the background of plenty of lymphocytes [Figure - 6] s/o Granulomatous inflammation of Koch's etiology.


   Discussion Top


Pancreas is biologically protected from infection by mycobacterium tuberculosis because of the presence of pancreatic enzymes, however when pathogen is able to overcome the resistance, the disease pattern can be varied. The exact way in which pancreas is involved is yet to be completely understood. But two main hypotheses have been proposed. One theory suggests that by hematogenous dissemination after pulmonary disease organisms reach pancreas [3].Another theory proposes that pancreatic tuberculosis can be caused by direct spread from adjacent peripancreatic lymphnodes [4]. Pancreatic tuberculosis can present clinically with non-specific symptoms such as fatigue, weight loss anorexia, fever, weight loss, sweating & chills. Abdominal pain, nausea occasionally with history of pancreatitis or gastrointestinal bleed [2]. Investigations generally fail to contribute to the diagnosis. Ultrasonography and CT normally suggest the presence of mass lesion in pancreas but are unable to rule out malignancy or make a specific diagnosis [1],[5].Various appearances noted on CT include nonspecific focal mass lesion in HIV sero negative patients, multiple small low attenuation pancreatic nodules, low attenuation peripancreatic and periportal adenopathies with peripheral rim enhancement[2]. In AIDS patient commonly observed ultrasound findings is diffusely hypoechoic slightly enlarged gland [6]. Another way of presentation can be cystic mass in pancreas [7],[8].

The varied presentation and rare occurrence of pancreatic tuberculosis is the main reason for its diagnosis becoming difficult and a high degree of suspicion is necessary for a pre or intra-operative diagnosis. USG or CT guided aspiration cytology may help in differentiating this from carcinoma, lymphoma, chronic pancreatitis or sarcoidosis [1].

 
   References Top

1.S.Varshney, CD Johnson Tuberculosis of pancreas Journal of postgraduate medicine 1995; 71:564-566.   Back to cited text no. 1    
2.F.Pombo, MJ Diaz Candamio, E.Rodriguez, S.Pombo Pancreatic Tuberculosis CT findings Abdominal imaging 1998;23: 394-397.   Back to cited text no. 2    
3.Stambler JB, K Libanr M1, Bliss CM, Lamont 3T Tuberculous abscess of pancreas Gastroenterology 1082; 82:922-925.   Back to cited text no. 3    
4.Stock K.P, Riemann JF, Stadler W, et al Tuberculosis of pancreas Endoscopy 1981; 13:178-180   Back to cited text no. 4    
5.Babu RD, John V Pancreatic Tuberculosis: case reports review of literature Trop Gastroenterol 2001; Oct-Dec, 22(4) : 213-4.   Back to cited text no. 5    
6.ET Tshibwabwa, P.Mwaba, J Bogle - Taylor, A.Zumla Four year study of abdominal ultrasound in 900 central African adults with AIDS referred for diagnostic imaging Abdominal imaging 2000; 25:290-296.   Back to cited text no. 6    
7.Terrence C.Demos, Harold V Posniak,Carla Harmath, Mary C Olson, Gerard Aranha cystic lesions of pancreas AJR 2002; 179:1375-1388.   Back to cited text no. 7    
8.Richard A.Leder, Viment H.S.Low Tuberculosis of the abdomen RCNA July 1995, vol 33, and No.4: 691-705.  Back to cited text no. 8    

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Correspondence Address:
K Uma
Nizam's Institute of Medical Sciences Panjagutta: Hyderabad (AP)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.28280

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

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