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Abstract
Pancreatic tuberculosis is a rare form of Tuberculosis (TB) which requires a high index of suspicion to diagnose. Here, we report a case of middle-aged gentleman presenting with abdominal pain and constitutional symptoms who was diagnosed with pancreatic tuberculosis on imaging, which was confirmed by Fine Needle Aspiration (FNA) from the lesion. The patient was given Anti-Tubercular Treatment (ATT) as per conventional protocol. Follow-up showed recovery from the entity. A review of patient presentation, patho-physiology, diagnosis, and management of pancreatic tuberculosis is mentioned in this article.
Keywords: Abdomen, cancer, pancreas, tuberculosis (TB)
How to cite this article: Introduction 
Tuberculosis (TB) can affect any organ in the human body. Abdominal tuberculosis forms an important type of extra-pulmonary tuberculosis, which commonly affects the ileocecal region. Organs like liver, spleen and kidney also tend to be affected by the disease. Pancreatic tuberculosis, however is an extremely rare form of TB especially in isolated form. Here we describe a case of pancreatic TB mimicking pancreatic carcinoma, which was efficaciously treated with antitubercular medications.
Case Report A 43-years male, chronic smoker, and alcoholic presented to the Surgery Outpatient Department with complaints of dull aching pain in the upper abdomen associated with loss of appetite and significant weight loss of 15 Kg in 3 months duration. There was no history of jaundice or melena. The patient did not have any comorbidities or history of past surgeries. The clinical examination revealed stable vitals and abdominal examination revealed a soft non-tender abdomen with an ill-defined mass palpable in the epigastric region. His complete blood counts, liver function, renal function, and coagulation profile were within normal limits. Ultrasound abdomen reported an ill-defined hypoechoic mass lesion 6 × 5 cm in retroperitoneum in supra-umbilical region. The mass lesion is seen encasing the SMV and SMA. Hence, Computed Tomography (CT) scan of the abdomen was done, which showed an ill-defined heterogeneous mass lesion in the uncinate process of the pancreas measuring 3.5 × 3.9 × 2.6 cm. The lesion was seen partially encasing the Superior Mesenteric Vein (SMV) and abutting Superior Mesenteric Artery (SMA). There was a large peripherally enhancing necrotic conglomerated lymph nodal mass with few calcifications in the peri-pancreatic region [Figure 1]. Blood tumor marker levels including Carbohydrate Antigen (CA 19-9) and Carcinoembryonic Antigen (CEA) were within the normal range (CA 19-9: 12 U/ml and CEA: 1.2 ng/ml). As the pancreatic mass was unresectable and there was diagnostic dilemma an image-guided biopsy from the lesion was done, which showed epithelioid granulomas surrounded by lymphocytic infiltrates [Figure 2]. Ziehl-Neelsen (ZN) stain done was positive for Acid Fast Bacilli. Hence, diagnosis of tuberculosis was made and he was started on Anti-tubercular treatment and managed symptomatically. On 3 months follow-up, the patient was asymptomatic and doing well and radiological imaging showed complete resolution of the lesion.
Figure 1: Shows ill-defined heterogeneous mass lesion in the uncinate process of pancreas partially encasing the SMV and abutting SMA. and enhancing necrotic conglomerated lymph node mass with few calcifications in peri-pancreatic region
Figure 2: (a) 100x H and E stained slide showing numerous necrotising epithelioid cell granulomas along with Langhan giant cells in fibroadipose tissue. (b and c) 200x and 400x H and E stained slide showing epithelioid cell granulomas along with Langhan cell and necrosis Discussion Robert Koch's in 1882 announced the discovery of Mycobacterium Tuberculosis as the cause of Tuberculosis. In the century following Koch's discovery, advances in prevention, diagnosis, and treatment of tuberculosis have come up. Yet, Tuberculosis stubbornly presents as a major worldwide health problem with an estimation of 10 million cases of TB occurring yearly.[1] It is estimated that nearly one-quarter of the world's population is infected with TB, and in 2018 approximately 10 million individuals became ill with the disease. TB accounted for 1.5 million deaths in the same year.[2] Globally TB incidence peaked in 2003 and there has been a slow decline in the number of cases. However, the total number of cases still forms a huge healthcare burden, especially in developing countries.[3] The main factors responsible for the resurgence of the global TB epidemic is due to poverty, Human Immunodeficiency Virus (HIV) infection, and drug resistance. Approximately 95% of TB cases occur in resource-limited countries. It is also estimated that every 1 in 12 new cases of TB occurs in individuals co-infected with HIV infection.
The most common site of infection of Mycobacterium Tuberculosis is the lungs. The tubercle bacilli reach the lungs of patient via droplet infection (5 to 10 microns in size). If the innate immunity of the body fails to eliminate the infection, bacterial proliferation occurs inside the alveolar macrophages. These bacilli can migrate from the lungs and enter other organs.[4] Abdominal tuberculosis comprises about 5% of all TB cases which can include the GI tract, peritoneum, lymph nodes, or solid organs.[5] Out of these, the most common occurrence is peritoneum, intestine, and lymph nodes. There are various mechanisms by which a person develops tuberculosis. In settings of active pulmonary Koch's or military tuberculosis, the disease occurs via hematogenous route. It can occur due to reactivation of infection especially in immunocompromised conditions and HIV infection. Gastrointestinal Tuberculosis can occur by ingestion of unpasteurized milk or undercooked meat. Contiguous spread can occur from adjacent organs like fallopian tubes or spread can occur via lymphatics.
Pancreatic tuberculosis is an extremely uncommon form of TB. The presentation of pancreatic tuberculosis is usually as abdominal pain, constitutional symptoms like loss of appetite, and weight loss, as described by Abbaszadeh et al.[6] The case series of 16 cases of pancreatic TB by Ray et al.[7] in 2020 showed epigastric pain as the most common symptom, seen in 80% cases, followed by weight loss in 75% cases and anorexia in 69% cases. Fever (50%), jaundice (31%) and abdominal lump (25%) were less common symptoms. Pancreatic tuberculosis is known as a great mimicker of pancreatic cancer. Since the most common presentation of pancreatic TB is as head mass and close resemblance to pancreatic adenocarcinoma; Whipple's procedure has been done in a lot of cases worldwide owing to the diagnostic dilemma. Awareness of pancreatic TB is necessary to make an early diagnosis and initiate treatment. Increased incidence of this entity in HIV infection is of clinical significance. A high degree of suspicion is needed for the early diagnosis and prompt treatment of this condition. The imaging modality of choice is Contrast-Enhanced CT scan of the abdomen which usually shows heterogeneous pancreas with solitary parenchymal lesions and peri-pancreatic lymph nodes. Ultrasound of abdomen as screening imaging tool can also be used. The findings noted in pancreatic tuberculosis on imaging are summarized in [Table 1].[8]
Table 1: Shows the common diagnostic features of pancreatic tuberculosisPanic et al.[9] in 2020 published a study on a systematic review of pancreatic tuberculosis where 116 studies reporting 166 diagnosed cases of pancreatic tuberculosis. 50% of cases of pancreatic tuberculosis were diagnosed in Asia followed by 22% in North America and 20% in Europe. HIV was the most common associated infection found in nearly 1/4th of the total patients. The most common presentation of pancreatic TB is in the form of mass (~80%). The frequency of distribution in the pancreas is as follows: Head (~59%), Body (18%), and Tail (13%). Auerbach et al.[10] reported 297 cases of miliary tuberculosis of which a 4.7% incidence of pancreas was noted. Extra pancreatic TB involved most commonly involved peripancreatic Lymph nodes (47%). The mortality rate of pancreatic tuberculosis despite treatment is ~8.7% which occurs in debilitated patients with significant co-morbidities. Summary of the characteristic of pancreatic tuberculosis has been described in [Table 2].
Table 2: Shows summary of the characteristics of pancreatic tuberculosisEven though pancreatic tuberculosis is an entity that poses a serious diagnostic dilemma, it is a potentially treatable condition. The gold standard of treatment of Pancreatic TB includes anti-tubercular drugs. The duration of treatment is the same as any other extrapulmonary TB which is 6 months. The drugs administered include Rifampicin (10 mg/kg/day), Isoniazid (5 mg/kg/day), Ethambutol (20 mg/kg/day), and Pyrazinamide (30 mg/kg/day). Pyridoxine is usually given along with isoniazid to prevent the occurrence of peripheral neuropathy. 2 months of all 4 drugs followed by 4 months of Rifampicin, Isoniazid and Ethambutol is routinely given for pancreatic tuberculosis. Pancreatic tuberculosis responds well to conventional anti-tubercular treatment as reported in all the studies.[11] However, multi-drug resistance and hepatotoxicity will require alternate treatment regimes.
Conclusion Pancreatic tuberculosis is a rare form of abdominal TB, which should be suspected in patients living in endemic regions of TB who present with pancreatic mass with peri-pancreatic lymphadenopathy. The symptoms of pancreatic tuberculosis are usually non-specific which includes pain abdomen, anorexia and weight loss. Ultrasound and CT scan findings can be misinterpreted as malignancy. Endoscopic Ultrasound (EUS) guided Fine Needle Aspiration (FNA)/Biopsy is the best way to definitively diagnose pancreatic tuberculosis. If the first image/EUS guided FNA fails, a repeat attempt can obviate the need for surgery. A laparotomy must be avoided as much as possible; minimal access approach might be a better option in cases of diagnostic dilemma. Conventional Anti-tubercular treatment achieves complete cure in most of the patients.
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References 
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CheckDOI: 10.4103/ijpm.ijpm_874_21
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