Solitary pancreatic tuberculous abscess mimicking pancreatic cystadenocarcinoma: a case report
© Liu et al; licensee BioMed Central Ltd. 2003
Received: 15 September 2002
Accepted: 10 January 2003
Published: 10 January 2003
The incidence of pancreatic tuberculosis is extremely rare, and it frequently misdiagnosed as pancreatic neoplasms. The nonsurgical diagnosis of this entity continues to be a challenge.
A 33 year old male with six-month history of intermittent right epigastric vague pain and weight lost had found a solitary pancreatic cystic mass and diagnosed as pancreatic cystadenocarcinoma. The chest X-ray film and physical examination revealed no abnormalities. Abdominal ultrasound (US) examination showed an irregular hypoechoic lesion of 6.6 cm × 4.4 cm in the head of pancreas, and color Doppler flow imaging did not demonstrate blood stream in the mass. The attempts to obtain pathological evidence of the lesion by US-guided percutaneous fine needle aspiration failed, an exploratory laparotomy and incisional biopsy revealed a caseous abscess of the head of pancreas without typical changes of tuberculous granuloma, but acid-fast stain was positive.
Pancreatic tuberculosis should be considered in the differential diagnosis of focal pancreatic lesions, especially for young people in developing countries.
Tuberculosis is common in developing countries, but tuberculosis affecting intraabdominal organs is relatively uncommon. Abdominal tuberculosis mainly involves abdominal lymph nodes and the ileocecal junction, other organs that are uncommonly involved included the rest of gastrointestinal tract, peritoneum, liver, and spleen [1, 2]. Pancreatic involvement is extremely rare. Because of difficulty of obtaining the pathological evidence and rare awareness of tuberculosis, it is very difficult to confirm the diagnosis, always misled by pancreatic neoplasms. Therefore, pancreatic tuberculosis should be kept in mind among the differential diagnosis of solitary masses in the pancreas, especially in young people in developing countries. A patient with pancreatic head tuberculosis mimicking pancreatic cystadenocarcinoma is reported, which was diagnosed by exploratory laparotomy to be a tuberculous abscess. The patient responded to antituberculous drugs after drainage of the abscess.
A 33 year old male was admitted to our hospital presenting with six-month history of intermittent right epigastric vague pain, and having lost 5 kg in weight over a 2-month period. According to the patient's history, he had had no coughing, fever, jaundice, diarrhea, hematemesis and melena. He had never received a BCG vaccine, but there was no prior history of tuberculosis, or any family history. One month ago, an abdominal computed tomography (CT) performed at another affiliated hospital of our University showed a pancreatic cystic mass, and diagnosed as pancreatic cystadenocarcinoma. On admission, the physical examination revealed no abnormalities.
Tuberculosis remains a major health problem in developing countries. In recent years developed countries too have seen a resurgence of this disease due to the human immunodeficiency virus (HIV) infection and other immunodeficient states. The development of abdominal tuberculosis is independent of pulmonary disease in most patients, with the reported incidence of coexisting disease varying from 5% to 38% , and abdominal tuberculosis affected the pancreas is rarely. Auerbach reported in 1944 that 4.7% of 297 autopsy cases of military tuberculosis involved the pancreas . Paraf et al in 1966 reviewed autopsy studies of military tuberculosis between 1891 and 1961 and found only an incidence of 2.1% (11/526) of pancreatic or peripancreatic involving . In 1977, Bhansali did not report a single case involvement of the pancreas in 300 patients with abdominal tuberculosis from India .
The pathogenesis of pancreatic tuberculosis is inconclusive because most cases are in the absence of any detectable lesions in the other parts of the body. It is speculated that the tubercle bacilli reach the pancreas through hematogenous dissemination from an occult lesion in the lungs or abdomen. Actually, the route by direct spread from contiguous lymph nodes may be responsible for most of the cases with isolated pancreatic tuberculosis. That the pancreas is offended directly and destroyed subsequently by peripancreatic or periportal tubercular lymphadenopathy / ymphadenitis is a more convincible explanation for this condition, because the findings from CT [5, 6] or the exploratory laparotomy  rarely demonstrate presenting absolute isolated pancreatic tuberculosis without adenopathies or other abdominal tubercular lesions, such as the present one. The pathological changes of adenopathy range from inflammatory exudates to caseous necrosis and abscess. The third possible way is that dormant bacilli in an old tubercular lesion can reactivate in an immunosuppressive state [6–8]. Stock et al in 1981 conceived of the toxic allergic reaction to generalized tuberculosis as a theoretical mechanism .
In our patient, he only presented with abdominal pain, weight loss, and minor ascites detected on laparotomy. Pancreatic tuberculosis could present with protean clinical manifestations, including upper abdominal pain, pyrexia of unknown origin, ascites, abdominal mass, obstructive jaundice, acute or chronic pancreatitis, upper gastrointestinal haemorrhage due to splenic vein thrombosis, diarrhea and weight loss. The nonspecific clinical and laboratory investigations combination with pancreatic masses on CT scan frequently lead to an erroneous primary diagnosis of a carcinoma , cystadenocarcinoma  or pseudocyst .
Abdominal CT and US may show an enlarged pancreas with focal hypodense or hypoechoic lesion, usually in the head region, sometimes with irregular multilobular cyst arising from pancreas, which was also seen in our patient. However, these findings are nonspecific and simulate solid and/or cystic pancreatic neoplasms [5, 6]. In fact, there are no cardinal differences between radiologic appearances of cystic neoplasm and tuberculous abscess of pancreas, both of them have septa within mass, cyst with internal echos, and nearby hypodense lymphadenopathy. Calcified rim of cyst wall  and mural nodulars  are suggestive of characteristic findings for cystic neoplasms, but these occasionally present. A diagnosis of tuberculosis that can be suggested only in the presence of ancillary findings like pulmonary tuberculosis, pleural effusion, enlarged celiac lymph nodes, lesions in other solid viscera, ascites, mural thickening in the ileocecal region [1, 5, 6, 13], or positive tuberculin test. The diagnosis of pancreatic tuberculosis can't be established without pathological confirmation by biopsy from FNA or exploration. US or CT-guided percutaneous FNA of tumor to obtain proof of the bacilli by the Ziehl-Neelsen stain or by culture is one diagnostic option, however, the aspiration of material from peripancreatic tumors or lymph nodes may be difficult, even if acid-fast stain for exact sampling, it showed to be positive only in 33~41% of cases of abdominal tuberculosis [14, 15]. Furthermore, the potential risk of tumor dissemination sometimes prevents the physicians to perform FNA. Concerning the cases of cystic neoplasm, however, Lo et al  concluded that the spillage of tumor cells by FNA has not been reported, and FNA should be considered in young patients presenting with a cystic pancreatic mass. The polymerase chain reaction (PCR) of ascites was reported sometimes useful for those the bacterial cultures were negative . Another diagnostic option involves initiating treatment with antituberculous drugs and evaluating the response of a tumor to this treatment. Nevertheless, the nonsurgical diagnosis of this entity continues to be a challenge, and laparotomy should be indicated to establish a diagnosis in most of the suspected cases. Other indications for an exploration are secondary complications, such as compression of common bile duct, or presenting gastrointestinal bleed.
In conclusion, a peripancreatic /pancreatic head cold abscess can mimic pancreatic cyst-adenoacarcinma. The clinican's high index of suspicion of tuberculosis and application of FNA to obtain pathological evidence are extremely important to a correct preoperative diagnosis. Provided diagnosis is established, anti-tuberculous chemotherapy or together with aspiration or pigtail drainage may be sufficient . Surgery should be reserved either to establish diagnosis or to deal with associated complications.
List of abbreviations
gamma glutamyl transferase
polymerase chain reaction
white blood cell
We thank the patient for giving us written consent for publishing his details.
- Hulnick DH, Megibow AJ, Naidich DP, Hilton S, Cho KC, Balthazar EJ: Abdominal tuberculosis: CT evaluation. Radiology. 1985, 157: 199-204.View ArticlePubMed
- Bhansali SK: Abdominal tuberculosis. Experience with 300 cases. Am J Gastroenterol. 1977, 67: 324-337.PubMed
- Auerbach O: Acute generalized military tuberculosis. Am J Pathol. 1944, 20: 121-136.PubMed CentralPubMed
- Paraf A, Menager C, Texier J: La tuberculose du pancreas et la tuberculose des ganglions de L'etage superior de L'abdomen. Rev Med-Chir Mal Foie. 1966, 41: 101-126.PubMed
- Pombo F, Diaz Candamio MJ, Rodriguez E, Pombo S: Pancreatic tuberculosis: CT findings. Abdom Imaging. 1998, 23: 394-397. 10.1007/s002619900367.View ArticlePubMed
- Takhtani D, Gupta S, Suman K, Kakkar N, Challa S, Wig JD, Suri S: Radiology of pancreatic tuberculosis: a report of three cases. Am J Gastroenterol. 1996, 91: 1832-1834.PubMed
- Memir K, Kaymakoglu S, Besisik F, Durakoglu Z, Ozdil S, Kaplan Y, Boztas G, Cakaloglu Y, Okten A: Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma. J Gastroenterol Hepatol. 2001, 16: 1071-1074. 10.1046/j.1440-1746.2001.02467.x.View Article
- Elizondo ME, Arratíbel JAA, Compton CC, Warshaw AL: Images in Surgery. Tuberculosis of the pancreas. Surgery. 2001, 129: 114-116. 10.1067/msy.2001.104364.View Article
- Stock KP, Riemann JF, Stadler W, Rosch W: Tuberculosis of the pancreas. Endoscopy. 1981, 13: 178-180.View ArticlePubMed
- Karia K, Mathur SK: Tuberculous cold abscess simulating pancreatic pseudocyst. J Postgrad Med. 2000, 46: 33-34.PubMed
- Bornman PC, Beckingham IJ: ABC of diseases of liver, pancreas, and biliary system: Pancreatic tumours. BMJ. 2001, 322: 721-723. 10.1136/bmj.322.7288.721.PubMed CentralView ArticlePubMed
- Martin I, Hammond P, Scott J, Redhead D, Carter DC, Garden OJ: Cystic tumours of the pancreas. Br J Surg. 1998, 85: 1484-1486. 10.1046/j.1365-2168.1998.00870.x.View ArticlePubMed
- Akhan O, Pringot J: Imaging of abdominal tuberculosis. Eur Radiol. 2002, 12: 312-23. 10.1007/s003300100994.View ArticlePubMed
- Kqduri VG, Janardhanan R, Hagan P, Brodmerkel GJ: Pancreatic TB: diagnosis by needle aspiration. Am J Gastroenterol. 1992, 87: 1206-1209.
- Lo SF, Ahchong AK, Tang CN, Yip AWC: Pancreatic tuberculosis: case reports and review of the literature. J R Coll Surg Edinb. 1998, 43: 65-69.PubMed
- Hashimoto M, Koyama H, Noie T, Shibayama K, Kitamura N: Abdominal tuberculoma mimicking a pancreatic neoplasm: report of a case. Surg Today. 1995, 25: 365-368.View ArticlePubMed
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/3/1/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.