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Pancreatic tuberculosis: a case report and literature review
Autor(es): Henrique Pereira Faria, José Torres Alves, Ovídio Carlos Carneiro Villela, Raul Moraes da França Filho, Milton Alves Romeiro
Keywords: Tuberculosis, Pancreas, Computed tomography
IMD, Trainee at Setor de Radiologia e Diagnóstico por Imagem do Hospital Márcio Cunha, Ipatinga, MG, and at Centro de Pesquisa e Pós-graduação da Faculdade de Ciências Médicas de Minas Gerais (CPG-FCMMG), Belo Horizonte, MG, Brazil
Tuberculosis is a common disease, but the pancreas involvementrarely occurs. The first cases were reported by Auerbach in1944(1).
Pancreatic tuberculosis pathogenesis is still to be known. Ithas been suggested that bacilli reach the pancreas bylympho-hematogenic dissemination from primary or secondarytuberculosis. The primary lesion may be intestinal, withpancreatic involvement originating from retroperitoneal lymphnodes(2). Clinical features are quite variable,many times mimicking characteristics of a pancreaticadenocarcinoma(3).
This paper presents a case of pancreatic tuberculosis in a39-year-old male patient manifesting pain in the superior abdomenand constitutional symptoms. The radiological workup and clinicalmanifestations are discussed.
Male, 39-year-old patient with previous history of alcoholism,reported intermittent epigastric pain for approximately thelatest 45 days, associated with nausea, vomiting and body weightloss. There was no history of pulmonary or gastrointestinaltuberculosis in the past.
Clinical signs at physical examination were normal. Total leukocyte counting was 2,700/mm³, with the following differential counting: segmented 63%, rods 22%, lymphocytes 9% and monocytes 6%; hemoglobin de 9.3 g/dl. No alteration was found on upper digestive endoscopy. Normal chest x-ray (Figure 1). During the hospital stay, the patient progressed with febrile peaks predominantly at evening.
Exploratory laparotomy revealed multiple whitish nodules in the pancreas, spleen and omentum (Figure 3). The hypothesis of peritoneal carcinomatosis was raised, and omentectomy, splenectomy and hygienization of the peripancreatic area. The histopathological study of the spleen and omentum demonstrated several epithelioid granulomas with central caseous necrosis (Figure 4), associated with few Langhans-type and foreign-body-type giant multinucleated cells. The Ziehl-Nielsen staining for acid-fast bacilli was positive.
The pancreas is rarely affected by tuberculosis. In 1944,Auerbach reported pancreatic involvement in 4.7% of biopsies incases of miliary tuberculosis(4). Between 1891and 1961, Paraf et al.(3) reported 11 cases ofpancreatic involvement in necropsies of miliary tuberculosis,with 2.1% incidence of involvement of this organ.
Between 1980 and 1998, 14 cases were reported in theliterature(5), the majority in young adults(mean age 33 years), with constitutional symptoms and epigastricpain. In eight cases, only the pancreas was affected. Thediagnosis was made by means of laparotomy in seven cases. Fineneedle aspiration biopsy was performed in six cases, two of themunder computed tomography guidance. The cytology suggestedtuberculosis in four cases. Therefore, fine needle aspirationbiopsy is recommended in the suspicion of pancreatic tuberculosisand differential diagnosis with pancreatictumor(6,7). Of then cases with tuberculinictest, eight were positive. This is a simple and low-cost testthat may be useful as a support for the clinical rationale inthese cases.
The diagnosis of pancreatic tuberculosis frequently may bedisregarded or postponed, unless there is an evidence ofpulmonary tuberculosis in another site. However, of the 14 casesin the literature(5), eight did not presentextrapancreatic lesions, and only three presented involvement ofthe lungs.
Pancreatic tuberculosis may present several signs andsymptoms, including pain in the upper abdomen, obstructivejaundice mimicking a tumor in the pancreatic head, fever ofundetermined origin, and non-specific symptoms like body-weightloss. The majority of cases presented constitutional symptoms andpain in the upper abdomen(5).
The diagnosis of pancreatic tuberculosis requires a high levelof suspicion and, although is a rare condition, should beconsidered as a differential diagnosis in patients withpancreatic lesions, particularly those with constitutionalsymptoms. The tuberculinic test may be of diagnostic value inthese cases. However, CT-guided fine needle aspiration emerges asa propedeutic method of choice because of its low-invasivenessand reasonable specificity.
Received April 25, 2005.
* Study developed in the Setor de Radiologia e Diagnóstico por Imagem do Hospital Márcio Cunha, Ipatinga, MG, Brazil.