Tbc

1. Disclosure Statement of Financial Interest
Dr Maghrebi Houcine
“Nothing To Disclose”

2. EP04B-015
Tuberculosis of the Pancreas: Diagnostic Challenges
H. Maghrebi, A. Heni, R. Rhaim, A. Makni, A. Daghfous, F. Fteriche,
M. Jouini, M. Kacem, Z. Bensafta
Department of general surgery , Rabta Hospital, Tunisia
Introduction :
Isolated tuberculosis of pancreas and peripancreatic lymphnodes is very rare. It presents with a
wide spectrum of symptoms. It is often mistaken for malignancy and can pose a diagnostic
challenge. In fact, most cases of pancreatic tuberculosis have been diagnosed after surgery
carried out for a suspected malignancy.
Aim: We report a case of an atypical peripancreatic tuberculosis, mimicking a carcinoma on
imaging technique and which was only diagnosed after a percutaneous biopsy of the mass.

3. Case report
Thirty one- year-old men presented with 2 months history of epigastric abdominal pain and weight
loss . His past medical history was unremarkable for chronic diseases or hospitalization.
Ultrasound and computed tomogram (figures 1+2) scan revealed a complex solid/cystic mass of the
of pancreas of 6 cm. Several large para-aortic necrotic lymph nodes, with node in the small bowel
mesentery were noted. Hepatic transaminases, alkaline phosphatase, Serum ACE, CA 19.9 were
within normal range. All other laboratory findings were normal.
Figure 1+2

4. Magnetic Resonance Cholangio Pancreatogram (MRCP) scan (Fig. 3) showed the same informations.
A percutaneous biopsy from the pancreatic mass and lymph nodes was performed. Cytology revealed
multiple granulomas with areas of caseating necrosis and clusters of multinucleated giant cells. Anti-
tuberculous therapy (ATT) was initiated (isoniazid, rifampin, ethambutol, and pyrazinamide for two months
and completed therapy with ten additional months of isoniazid and rifampin). The symptoms resolved and
follow-up imaging showed a complete resolution of the mass, lymphadenopathy and symptoms.
Figure 3: Magnetic Resonance Cholangio Pancreatogram

5. Discussion:
• Tuberculosis (TB) is a major health problem worldwide. Even in endemic areas, pancreatic TB is uncommon.
• The clinical features of pancreatic TB is uncommon and indistinguishable from a pancreatic neoplasm. It include
weight loss, anorexia, abdominal pain, fever, night sweats…. Patients may present with a pancreatic mass lesion
such our patient .
• The most common location of PPT as a mass has been reported in the head or body as in our cases.
• US and CT scan may show a diffusely enlarged pancreatic mass lesion. These findings are non-specific and may be
seen with focal pancreatitis of any etiology, similar to pancreatic carcinoma. The common bile duct and the
pancreatic duct have been reported to be normal. The presence of hypodense lymph nodes with rim enhancement in
the peripancreatic region, ascites and/or mural thickening in the ileo-cecal region may suggest the possibility of TB.
• Due to the lack of pathognomic radiological features for pancreatic TB, most cases have been diagnosed in the past
at laparotomy performed for a suspicion of pancreatic malignancy. Few cases have been diagnosed by fine needle
aspiration cytology/biopsy.
• The role of ultrasound/endoscopic ultrasound-guided fine-needle aspiration cytology/biopsy has proven to be an
excellent tool for the cytological diagnosis of pancreatic and peripancreatic masses.
• Most cases of pancreatic tuberculosis respond well to anti-tubercular treatment with isoniazid /Rifampin/
Pyrazinamide/ Ethambutol or Streptomycin for 6-12 months as in our cases.

6. Références
1. Rezeig MA, Fashir BM, Al-Suhaibani H, Al-Fadda M, Amin T, Eisa H. Pancreatic tuberculosis mimicking pancreatic carcinoma: four case reports and
review of literature. Dig Dis Sci 1998;43:329 – 331.
2. Kouraklis G, Glinavou A, Karayiannakis A, Karatzas G. Primary tuberculosis of the pancreas mimicking a pancreatic tumour. Int J Pancreatol
2001;29:151 – 153.
3. Schneider A, von Birgelen C, Duhrsen U, Gerken G, Runzi M. Two cases of pancreatic tuberculosis in nonimmunocompromised patients. A
diagnostic challenge and a rare cause of portal hypertension. Pancreatology 2002;2: 69-73.
4. Weiss ES, Klein WM, Yeo CJ. Peripancreatic tuberculosis mimicking pancreatic neoplasia. J Gastrointest Surg 2005;9: 254 – 262
5. De Backer AI, Mortele KJ, Bomans P, De Keulenaer BL, Vanschoubroeck IJ, Kockx MM. Tuberculosis of the pancreas: MRI features. AJR Am J
Roentgenol 2005;184: 50- 54.
6. D’Cruz S, Sachdev A, Kaur L, Handa U, Bhalla A, Lehl SS. Fine needle aspiration diagnosis of isolated pancreatic tuberculosis. A case report and
review of literature. JOP 2003; 4: 158 – 162.
7. Chang KJ, Nguyen P, Erickson RA, Durbin TE, Katz KD. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis
and staging of pancreatic carcinoma. Gastrointest Endosc 1997; 45: 387 – 393.
Conclusion :
Pancreatic tuberculosis is very rare and it closely resembles a pancreatic malignancy. Despite its rarity, it
should be considered for differential diagnosis of pancreatic mass in endemic developing countries.
Improvement in imaging techniques and the resulting image-guided interventions have helped us in the
preoperative diagnosis of pancreatic masses.