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Primary Pancreatic Tuberculosis: A Diagnosis and Therapeutic Dilemma. A Case Report

Gustavo Kohan, Ornella A Ditulio, Roberto F Klappenbach, Alejandro Faerberg, Oscar Imventarza

Context Primary pancreatic tuberculosis is an uncommon disease that can simulate a pancreatic cancer in symptoms as well as in imaging studies. Extrapulmonary tuberculosis can compromise different organs, including the ileocecal region, the peritoneum or different organs such as the spleen, liver and pancreas. Case report A Fifty-two-year-old female presented with a history of abdominal pain and jaundice. There was no history of pulmonary tuberculosis or other diseases. Ultrasonography and computed tomography scan showed dilation of the bile duct and an irregular and hypodense lesion in the pancreatic head. Preoperative imaging studies, laboratory findings and no evidence of pulmonary tuberculosis suggested a resectable pancreatic head neoplasm at surgery, two resectable yellowish lesions located in the pancreatic head were found and a conventional pylorus-preserving pancreatoduodenectomy was performed with standard lymphadenectomy. The pathologic analysis revealed pancreatic parenchyma with chronic inflammatory granulomatous reaction with Langhans´ giant cells with areas of caseous necrosis. The Ziehl Neelsen stain confirmed the presence of Koch`s bacillus in the necrosis areas. Conclusions Primary pancreatic tuberculosis is extremely rare and diagnosis is a real challenge. Imaging studies are non-specific and do not allow differentiation with an adenocarcinoma, being the fine needle aspiration the only way of preoperative diagnosis. However, since fine needle aspiration is not part of the diagnostic algorithm in a resectable pancreatic tumor, most cases of primary pancreatic tuberculosis are diagnosed postoperatively.