ISOLATED PANCREATIC TUBERCULOSIS WITH DUODENAL FISTULA: A CASE VIDEO REPORT

AKK LIM-FERNANDEZ, MD, RA VALLAR, MD
Institute of Digestive and Liver Diseases St. Luke’s Medical Center – Quezon City, Metro Manila, Philippines

Significance: Isolated pancreatic tuberculosis (TB) is an uncommon form of gastrointestinal TB even in an endemic countries.1 It is reported in less than 5% of cases occurring usually in disseminated TB and immunocompromised conditions. Symptoms include abdominal pain, fever and weight loss. Its appearance on radiologic imaging can mimic pancreatic malignancy, becoming a diagnostic challenge. In this case report, we present a case of isolated pancreatic TB presenting as pancreatic mass in imaging studies, which can be confused with malignancy.

Clinical Presentation: Our patient is a 56 year-old Filipino male, immunocompetent, without known comorbidities, presented with fever and chills, epigastric pain, poor appetite and weight loss. There was epigastric tenderness noted on examination.

Management: A contrast enhanced CT scan and MRI of the abdomen showed pancreatic mass with prominent lymph nodes. An EUS – guided FNA of the said mass revealed a pancreatic cystic mass at the uncinate process with noted fistulous tract to the duodenum. A re-biopsy was done at the fistulous tract in the duodenum to collect more samples for TB work-up for a more definitive diagnosis. He was then managed as isolated pancreatic TB with fistulous tract formation to the duodenum and was treated successfully with anti-tuberculous drugs. On follow up after 3 months, there was weight gain, resolution of fever and abdominal pain.

Recommendation: Pancreatic tuberculosis presenting as pancreatic mass may mimic malignancy leading to misdiagnosis. Providing enough tissue samples to establish TB is warranted to guide us in managing these patients and avoid unnecessary surgery.

Conclusion: Isolated pancreatic TB is a rare clinical entity. The diagnosis of a pancreatic TB is challenging due to nonspecific symptoms as well as imaging findings that can mimic pancreatic malignancy. EUS-FNA with biopsy is the preferred method to aid in differentiating a benign mass from a neoplasm. Sample specimens should be submitted for cytology, AFB staining, cultures and PCR assay for a better diagnostic yield. Most patients responds well to the anti-tuberculous therapy and achieve complete cure after completing the regimen.

Keywords: case report, pancreatic tuberculosis, abdominal tuberculosis, pancreatic mass, endoscopic ultrasound

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