Creighton University, Dignity Health St. Joseph's Medical Center Phoenix, AZ, United States
Award: Presidential Poster Award
Shehroz Aslam, MD1, Zaid Ansari, MD2, Osama Qasim Agha, MD3, Hadiatou Barry, MD2, Keng-Yu Chuang, MD2 1Creighton University, Dignity Health St. Joseph's Medical Center, Phoenix, AZ; 2Creighton University School of Medicine Phoenix Program, Phoenix, AZ; 3St. Joseph's Hospital and Medical Center, Creighton University School of Medicine, Phoenix, AZ
Introduction: Extrapulmonary tuberculosis (TB) is characterized by evidence of TB outside the lungs. While abdominal TB has been reported in the literature, pancreatic involvement is exceedingly rare. Here we report an interesting case of a patient who was diagnosed with pancreatic TB after presenting with abdominal pain and found to have peripancreatic lymphadenopathy.
Case Description/Methods: A 61 years old Hispanic male presented with generalized abdominal pain and pleuritic chest pain for the past few weeks. Also, he reported intermittent diarrhea, lack of appetite, and a 4‐5 pounds weight loss. Vital signs were stable and he had mild epigastric and chest wall tenderness on physical exam. Abnormal labs included T Bili 1.4 mg/dl, AST 62 U/L, and ALT 83 U/L. A CT scan of the abdomen showed peripancreatic edema and a 1.8 cm hypoenhancing region in the pancreatic body (Figure 1a). MRI of the abdomen revealed peripancreatic lesions measuring up to 3 cm likely representing necrotic lymph nodes with periportal lymphadenopathy (Figure 1b). To rule out malignancy, endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) of periportal lymph node was performed and revealed granulomatous inflammation with negative acid-fast bacilli (AFB) stain. No malignant cells were seen. Based on biopsy results, interferon-γ release assay (QuantiFERON) was checked and resulted positive. Subsequent chest imaging showed no evidence of pulmonary TB. The infectious disease team recommended checking lymph node AFB cultures to confirm extrapulmonary TB. On repeat EUS, peripancreatic lymphadenopathy (19 mm x 13 mm) was noted and FNB this time showed focal necrotizing granulomatous inflammation with rare AFB on the stain (Figure1c). AFB cultures confirmed the Mycobacterium TB complex. Anti-tubercular therapy (ATT) was started and the patient was discharged home with close outpatient follow-up.
Discussion: Pancreatic TB is a deceptive clinical entity considering its similarities with pancreatitis and pancreatic malignancy on imaging. The presentation ranges from fever, night sweats, malaise, anorexia, abdominal pain, weight loss, and jaundice. While diagnosis requires high clinical suspicion, EUS with FNB of the pancreatic lesion or lymph node is often diagnostic. Treatment involves ATT lasting for 6-12 months. The response to treatment is complete and requires close follow-up to ensure resolution and to rule out concomitant etiologies such as malignancy in high-risk patients.
Figure: Figure 1, a: Computed tomography image showing pancreatic edema and hypoehancing region in the pancreatic body, b: Magnetic resonance imaging showing peripancreatic lymph nodes, c: Rare acid-fast bacilli noted on the stain
Shehroz Aslam indicated no relevant financial relationships.
Zaid Ansari indicated no relevant financial relationships.
Osama Qasim Agha indicated no relevant financial relationships.
Hadiatou Barry indicated no relevant financial relationships.
Keng-Yu Chuang indicated no relevant financial relationships.
Shehroz Aslam, MD1, Zaid Ansari, MD2, Osama Qasim Agha, MD3, Hadiatou Barry, MD2, Keng-Yu Chuang, MD2. P2155 - Isolated Pancreatic Hideout of Mycobacterium Tuberculosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.