Miliary tuberculosis (TB) is a diagnostic challenge for clinicians. Pancreatitis as a presenting symptom is an extremely rare manifestation of miliary TB.
A previously healthy 31-year-old male was admitted because of severe nausea, malaise and night sweats for four days. He denied other constitutional symptoms. He did not smoke, use alcohol or drugs. He was born in the United States; lived in Manhattan and worked for a computer company. He kept no pets and had no recent travel. He took no medications and had no allergies.He was febrile (103° F); heart rate was 79; and respirations were 17. The blood pressure was 100/60 mm Hg, and the oxygen saturation was 100% on room air. The physical examination was unremarkable. The admission labs were signficant for leukopenia(2.7 x 10^9/L), thrombocytopenia(118 x 10^9/L), mild transaminemia and high lipase (=260 U/L; normal 66). He was HIV negative and PPD positive (12 mm).The admission chest x-ray (CXR) was normal (below):Computed tomographic (CT) evaluation of the abdomen was consistent with pancreatitis. On the 12th hospital day the patient complained of dyspnea. CXR and the CT scan images are shown:Patient underwent bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) which showed alveolar macrophages without granulomas, vasculitis or acid fast bacilli (AFB). Open lung biopsy (OLBx) revealed multiple necrotizing granulomas:The patient showed remarkable improvement on antituberculous therapy and was discharged home three weeks latter on direct observed therapy.DISCUSSION: TB pancreatitis has a wide spectrum of non specific clinical presentations. Rarely pancreatitis may be the only manifestation of unrecognized miliary TB. The only case report of pancreatitis occuring before miliary TB was puplished in 1978. Our case is unusual, because the admission CXR was normal, sputum smears, BAL and TBBx were negative for AFB. The diagnosis was confirmed with OLBx.
Miliary TB is generally a curable disease, which takes many forms. A high index of suspicion and diagnostic persistence are required for diagnosis.
N.P. Hadjiangelis, None.