S1412 Pancreatic Tuberculosis: A Challenging Diagnosis

INTRODUCTION: Pancreatic tuberculosis is an exceedingly rare condition, even in areas of the world where the disease is highly prevalent. Its presenting features are usually vague and non-specific, while the radiological features mimic pancreatic malignancy in many cases and pancreatitis in others. CASE DESCRIPTION/METHODS: A 26 years old active military male, originally from Virginia with no past medical history presented to the emergency department with a two-week history of abdominal pain, vomiting, dark urine, and pale stool. His physical examination was remarkable for scleral icterus as well as generalized abdominal tenderness. His laboratory results were remarkable for an alkaline phosphatase of 583 U/L, total bilirubin of 4.7 mg/dL, and direct bilirubin of 3.9. A CT scan and subsequent MRI of the abdomen showed a pancreatic mass at the body obstructing the common bile duct and causing intrahepatic bile dilation. ERCP/ EUS was performed showing a biliary stricture in the middle of the common bile duct for which a stent was placed, and fine-needle aspiration of the pancreatic mass was performed which was consistent with necrotizing granulomatous lymphadenitis. A stain of the pancreatic fluid were negative for TB. The infectious disease team was consulted and conducted a full infectious workup including HIV, Hepatitis panel, CMV DNA quantitative PCR, Quantiferon-TB gold, Ova and parasite, Histoplasma antigen, Blastomyces serology, RPR which all came back negative. All noninfectious causes of granulomatous disease were ruled out. A CT thorax was ordered and showed hilar and mediastinal lymphadenopathy as well as a nodule in the right upper lobe centrally. The patient subsequently underwent a Bronchoscopy with Broncho-alveolar lavage and bronchial brushing which came back negative for Pneumocystis jiroveci, Legionella pneumophilia, Mycoplasma Pneumoniae, fungal infections, and AFP stain. A Mycobacterium PCR of the pancreatic fluid culture was analyzed and showed Mycobacterium tuberculosis DNA complex. DISCUSSION: Increased awareness of pancreatic TB existence in clinical conditions associated with immunocompetence is needed. Increased awareness among clinicians might dampen the health care-cost associated with unnecessary diagnostic tests. We also encourage that EUS-guided biopsy be a crucial step in the diagnostic algorithm in pancreatic lesions in order to spare patients from risky surgical procedures.Figure 1.: EUS demonstrating 30 mm by 26 mm hypoechoic lesion.Figure 2.: ERCP demonstrating 1.5 cm biliary stricture in the middle of the common bile duct.Figure 3.: Fine needle aspiration of the pancreatic body showing necrotizing granulomatous inflammation. (Papanicolaou stain, 40X).