Meet Parikh, DO1, Vikram Patel, MD2, Adib Chaaya, MD2; 1Cooper University Hospital, Paramus, NJ; 2Cooper University Hospital, Camden, NJ
Introduction: Malignancy is often the culprit after discovery of an isolated pancreatic mass. It is important to consider other etiologies including infectious etiologies such as tuberculosis.
Methods: A 28 year old Vietnamese immigrant with no significant medical history presented with intermittent nausea and epigastric pain for several years that acutely worsened over two days. She reported the pain radiated to her back and was exacerbated by spicy foods. She denied any fevers, weight loss, or jaundice. Lipase and liver function tests were normal. CT imaging of the abdomen showed a 4cm heterogeneous hypodense pancreatic lesion but was otherwise normal (Figure 1a). EUS was notable for hypoechoic mass in the pancreatic head with irregular margins and no vascular invasion (Figure 1b). Fine needle aspiration cytology revealed granulomatous inflammation with extensive necrosis and negative AFB/GMS stains. Quantiferon Gold testing was positive and HIV testing was negative. Chest x-ray was normal. She had no prior history of tuberculosis and no known high risk exposures. Her immigration medical testing in 2012 was reportedly normal. In light of the pathologic and serologic findings, the patient was treated for isolated pancreatic tuberculosis with RIPE therapy. Her gastrointestinal symptoms resolved on therapy and follow-up CT imaging 6 months after completion of antibiotics showed complete resolution of the pancreatic mass. Discussion: The gastrointestinal tract is the 6th most common site of extrapulmonary tuberculosis and is seen in only about 5% of all tuberculosis cases; the ileocecal region is involved in the majority of cases. Isolated pancreatic tuberculosis is considered an extremely rare entity since pancreatic enzymes usually destroy any intrusive pathogens. These patients are typically immunocompromised. Abdominal pain and jaundice are well-known symptoms but weight loss and fevers and also commonly seen. Imaging will show a hypodense mass without any biliary ductal dilation or vascular invasion. EUS with fine needle aspiration is done for initial investigation while excisional biopsy is the most accurate diagnostic tool. Patients tend to respond very well to antituberculosis therapy. We present a unique case of an immunocompetent patient with dyspeptic symptoms who had no prior personal history of tuberculosis or known high risk exposure and was found to have isolated pancreatic tuberculosis.
Fig 1a. Initial CT abdomen/pelvis showing a multilobulated heterogeneous pancreatic mass (red circle)
Fig 1b. EUS findings notable for a 4cm x 4cm pancreatic head mass with irregular outer margins
Disclosures: Meet Parikh indicated no relevant financial relationships. Vikram Patel indicated no relevant financial relationships. Adib Chaaya indicated no relevant financial relationships.