Disseminated tuberculosis(TB) is a relatively uncommon entity. Within this entity, pancreatic involvement is very rare. We present a case with simultaneous pancreatic and thoracic foci of TB.
A 31-year-old man was referred for evaluation of two weeks of jaundice with associated nausea, emesis, and dyspepsia. He had a recent 10-pound weight loss but denied any right upper quadrant pain, diarrhea, melena, hematochezia, fever, chills, night sweats, greasy stools or dark urine. Though incarcerated at a state facility, he had been quite healthy and physically active and was not taking any medications. A recent tuberculin skin test(PPD) was nonreactive. Physical exam findings were significant for scleral icterus in an otherwise very healthy-appearing man. The lungs were clear and the cardiac exam was normal. Abdominal exam was unremarkable. There was no lymphadenopathy, skin lesions, or rash. Initial laboratory testing showed the following: white blood count 7.9 K/mm3, hemoglobin 11.1g/dl, platelet count 610 K/mm3, total bilirubin 8.7mg/dl, direct bilirubin 7.2mg/dl, aspartate aminotransferase 150U/L, alanine aminotransferase 196U/L, alkaline phosphatase 735U/L. Amylase, lipase, coagulation studies, urea nitrogen, creatinine, and calcium levels were within normal limits. Abdominal ultrasound showed a large mass in the head of the pancreas. Computed tomography(CT) revealed a cystic pancreatic lesion with associated diffuse intrahepatic ductal dilatation. During the work-up the patient developed a new cough. A chest x-ray revealed an isolated mediastinal lesion. CT of the thorax showed an 8cm right paratracheal mass with possible invasion into the distal trachea and right mainstem bronchus. A 3mm noncalcified nodule was seen in left lower lobe. CT-guided biopsy of the pancreatic mass showed fragments of fibrous tissue, necrotizing granulomas, and acute and chronic inflammation. Bronchoscopy demonstrated an endobronchial mass in the right mainstem bronchus. Biopsies showed granulomatous inflammation with necrosis and cellular atypia. Special stains were negative for bacteria, fungal organisms, and acid-fast bacilli(AFB). Three induced sputums were negative for acid-fast bacilli. Repeat PPD was nonreactive. HIV antibody testing and a viral hepatitis panel were negative. The patient was begun empirically on isoniazid, rifampin, ethambutal, and pyrazinamide. He was discharged back to the Department of Corrections for further follow-up and treatment. Shortly thereafter, mycobacterium tuberculosis was isolated from cultures of the pancreatic aspirate and the endobronchial biopsies. The strain was sensitive to all of the above medications. Six weeks after discharge, the patient was clinically stable and asymptomatic.
Since 1985, the incidence of tuberculosis in the United States has been increasing. Most of this increase appears to be accounted for by the increase in cases in patients with HIV. The unique aspect in this case is the presence of TB in simultaneous mediastinal and pancreatic masses. Isolated pancreatic TB is a rare condition with only a small number of case reports. Most commonly, pancreatic involvement is associated with miliary TB. In contrast to this patient’s presentation, miliary TB is usually associated with clinically significant pulmonary disease. Pancreatic TB causing obstructive jaundice is an exceedingly rare entity. The diagnosis often will be missed and subsequent treatment delayed in the absence of a strong clinical suspicion. A CT-guided aspiration or biopsy is the initial diagnostic procedure of choice. The most commonly considered alternative diagnosis is pancreatic or ductal carcinoma. However, this patient’s age and short duration of symptoms argue against a malignancy.
This is a very unusual and potentially misleading presentation of extrapulmonary TB. Despite AFB smear-negative biopsies, TB should be suspected in younger patients with significant risk factors in the appropriate clinical setting. Characteristic histological changes are often sufficient evidence for initiating anti-tuberculosis treatment in such a context.
G.H. McKinnis, None.