Metastatic Pancreatic Adenocarcinoma With All Signs Pointing at an Active Tuberculosis Infection

Abstract Introduction. Pulmonary metastases secondary to pancreatic adenocarcinoma are common, however a miliary pattern of such metastases is rare. In young patients, miliary pulmonary nodules are commonly due to infectious etiologies. We present a 34-year-old male initially admitted for shortness of breath and abdominal discomfort, and subsequently diagnosed with pancreatic adenocarcinoma despite the absence of a primary pancreatic lesion. Evaluation of the miliary pulmonary nodules and pleural effusions secured the diagnosis, and the clinical progression was rapid over the course of three weeks. Case Presentation. A 34-year-old male from Mexico with a history of gastritis and polysubstance use presented with generalized abdominal discomfort radiating to the back refractory to bismuth subsalicylate and omeprazole for 3 weeks associated with a 20 lb weight loss, decreased oral intake, and 3 days of subjective fevers, chills, night sweats, pleuritic chest pain, and dry cough. He was hemodynamically stable on admission, saturating well on room air. Laboratory studies showed mild leukocytosis (12.7) and elevated lipase (125). Computed tomography (CT) showed pancreatitis and diffuse pulmonary interlobular septal thickening with ground glass opacities, noncalcified pulmonary nodules, and calcified granulomas (Figure 1A). Further workup revealed a positive QuantiFERON test and thus esophagogastroduodenoscopy was postponed. There was high suspicion for active tuberculosis due to his clinical symptoms, history of living in Mexico, and miliary pattern of pulmonary nodules. Subsequent bronchoscopy with biopsies and bronchial alveolar lavage revealed primary pancreatic adenocarcinoma. Fungal and acid-fast staining were unremarkable. Although chemotherapy was planned, he developed acute hypoxic respiratory failure eventually requiring intubation due to superimposed pneumonia, rapidly developing malignant pleural effusions, and worsening multifocal metastases (Figure 1B). The metastases were likely the most significant contributor to hypoxia as antibiotics and bilateral thoracenteses did not improve his oxygenation. After unsuccessful breathing trials and significant lymphangitic spread of malignancy, he decided to be terminally extubated. Discussion. This rare presentation of metastatic pancreatic adenocarcinoma in a young patient demonstrates the diagnostic challenge involved due to atypical symptoms and imaging suggesting an infectious etiology. Malignancy must be considered as a differential diagnosis with the unique combination of pulmonary metastases with a miliary pattern, the patient's age, acute symptom onset, noncontributory family history, and the absence of elevated liver function enzymes, a primary pancreatic lesion, and biliary dilatation on imaging. Additionally, his rapid clinical deterioration and progression of respiratory failure emphasizes the aggressive nature and associated fatality of such malignancy; he succumbed 23 days after presentation.