Jianfeng Cheng, Kiranmayi Tadi, Michelle Halpern, Mirela Feurdean, Joseph McNelis, Jeffrey Brensilver, Department of Medicine, Sound Shore Medical Center of Westchester, 16 Guion Place, New Rochelle, NY 10801, United States

Correspondence to: Jianfeng Cheng MD, PhD, Department of  Medicine, Sound Shore Medical Center of Westchester, 16 Guion Place, New Rochelle, NY 10801, United States. jcheng794@gmail.com

Telephone: +1-347-3068322  Fax: +1-914-3655489

Received: July 8, 2007            Revised: August 20, 2007

Abstract

Despite the increased incidence of tuberculosis related to human immunodeficiency virus (HIV) in recent decades, pancreatic tuberculosis has rarely been described. We report a case of pancreatic tuberculosis in a 39-year-old African man who presented with progressive dysphagia, vomiting, weight loss and productive cough, accompanied by localized epigastric pain and one episode of melena. HIV-1 testing was positive and lymphocyte subset profile showed CD₄ count of 9/mm³. Abdominal computed tomography (CT) scan with contrast revealed a cystic mass in the body of the pancreas, significant portal and retroperitoneal cystic adenopathy, and multiple cystic lesions in the spleen and liver. CT guided cyst aspiration and node biopsy detected Mycobacterium tuberculosis. The patient responded well on antituberculosis and antiretroviral therapy. Tuberculosis rarely involves the pancreas, probably due to the presence of pancreatic enzymes which interfere with the seeding of Mycobacterium tuberculosis. Pancreatic tuberculosis is considered to be the result of dissemination of the infection from nearby lymphatic nodes. Endoscopic ultrasound or CT guided fine needle aspiration for cytology is the recommended diagnostic technique. Although the prognosis is good with anti-tuberculosis treatment, it could be fatal without correct diagnosis and treatment. The clinician’s high index of suspicion of pancreatic tuberculosis and application of FNAB to obtain pathological evidence are extremely important to a correct diagnosis, especially in young HIV positive patients.

© 2008 WJG. All rights reserved.

Key words: Pancreatic tuberculosis; Human immun-odeficiency virus infection; CT-guided fine needle biopsy

Peer reviewer: Peter Draganov, Dr, University of Florida, 1600 SW Archer Rd., Gainesville, FL 32610, United States

Cheng J, Tadi K, Halpern M, Feurdean M, McNelis J, Brensilver J. Pancreatic tuberculosis in a human immunodeficiency virus positive patient: A case report. World J Gastroenterol 2008; 14(6): 939-940  Available from: URL: http://www.wjgnet.com/1007-9327/14/939.asp  DOI: http://dx.doi.org/10.3748/wjg.14.939

INTRODUCTION

Subsequent to the AIDS epidemic, the incidence of tuberculosis has slowly increased in developed countries^[1]. However, pancreatic tuberculosis is rarely described in the literature. We report a case of pancreatic tuberculosis with abdominal dissemination which presented with progressive dysphagia, weight loss and epigastric pain.

CASE REPORT

A 39-year-old African man presented with a six months progressive dysphagia, vomiting and 30 lb weight loss, productive cough for three weeks, accompanied by localized epigastric pain and one episode of melena. He had a history of positive PPD 4 years earlier with normal chest radiograph and had not received isoniazid prophylaxis. Physical examination revealed a 101 F temperature, marked pallor, sinus tachycardia, epigastric and right upper quadrant tenderness. Investigations showed a WBC count of 1.7 × 10³/mm³ (normal range, 4.8-10.8 × 10³/mm³), anemia with hemoglobin at 5.1 g/dL (normal range, 14.0-18.0 g/dL), amylase 148 U/L (normal range, 30-110 U/L), lipase 29 U/L (normale range, 4-66 U/L) and LDH 551 U/L (normal range, 102-190 U/L). Chest radiograph, liver and renal function were normal. HIV-1 test was positive and lymphocyte subset profile showed CD₄ count of 9/mm³. A barium swallow showed a normal esophagus. Abdominal ultrasound revealed a cystic pancreatic mass, lymph node enlargement and cholelithiasis. The blood, urine and sputum culture were negative. Abdominal computed tomography (CT) scan with contrast revealed a cystic mass in the body of the pancreas with significant portal and retroperitoneal adenopathy and multiple cystic lesions in the spleen and liver (Figure 1). CT guided cyst aspiration and node biopsy detected inflammatory cells, necrotic tissue and many AFB bacilli. PCR testing was positive for Mycobacterium tuberculosis. The patient clinically improved on antituberculosis medications: ethambutol, isoniazid, vitamin B6, pyrazinamide, rifampin and moxifloxacin. Five months later, a repeat ultrasound revealed resolution of the pancreatic cyst and adenopathy.

DISCUSSION

Tuberculosis uncommonly involves the pancreas, which is thought to be biologically protected from the infection of Mycobacterium tuberculosis. Probably, this is because the presence of pancreatic enzymes which interfere with the seeding of Mycobacterium tuberculosis^[2]. Pancreatic tuberculosis is considered the result of the dissemination of the infection from near lymphatic nodes. A wide spectrum of symptoms has been reported. It ranges from abdominal pain, constitutional symptoms to such as weight loss, night sweat and anorexia, fever, obstructive jaundice^[3,4], to massive gastro-intestinal bleeding^[5] and iron deficiency anemia, pancreatic abscess^[6]. In addition, acute pancreatitis^[7], secondary diabetes^[8] and chronic pancreatitis^[9] have been also reported. Similar to the present case, the pancreatic cystic mass can mimic pancreatic cystic neoplasm^[10,11]. Abdominal tuberculosis is independent of pulmonary disease in most patients, with the reported incidence of coexisting disease varying from 5% to 38%. Endoscopic ultrasound or computed tomography-guided fine-needle aspiration biopsy (FNAB) is recommended for diagnosis^[12]. The prognosis is good with anti-tuberculosis treatment. However, it could be fatal without correct diagnosis and treatment^[13]. Wide spectrum of symptoms and occurrence in the absence of chest disease make it difficult to diagnose. The clinician's high index of suspicion of pancreatic tuberculosis and application of FNAB to obtain pathological evidence are extremely important to a correct diagnosis, especially in young HIV positive patients.

REFERENCES

1         Shukla HS, Hughes LE. Abdominal tuberculosis in the 1970s: a continuing problem. Br J Surg 1978; 65: 403-405        PubMed

2         Franco-Paredes C, Leonard M, Jurado R, Blumberg HM, Smith RM. Tuberculosis of the pancreas: report of two cases      and review of the literature. Am J Med Sci 2002; 323: 54-58   PubMed

3         Crowson MC, Perry M, Burden E. Tuberculosis of the pancreas: a rare cause of obstructive jaundice. Br J Surg 1984;      71: 239   PubMed

4         Chen CH, Yang CC, Yeh YH, Yang JC, Chou DA. Pancreatic tuberculosis with obstructive jaundice--a case report. Am J      Gastroenterol 1999; 94: 2534-2536   PubMed

5         Fan ST, Yan KW, Lau WY, Wong KK. Tuberculosis of the pancreas: a rare cause of massive gastrointestinal bleeding.      Br J Surg 1986; 73: 373   PubMed

6         Stambler JB, Klibaner MI, Bliss CM, LaMont JT. Tuberculous abscess of the pancreas. Gastroenterology 1982; 83:      922-925   PubMed

7         Rushing JL, Hanna CJ, Selecky PA. Pancreatitis as the presenting manifestation of miliary tuberculosis. West J Med      1978; 129: 432-436   PubMed

8         Patankar T, Prasad S, Laxminarayan R. Diabetes mellitus: an uncommon manifestation of pancreatic tuberculosis. J      Assoc Physicians India 1999; 47: 938-939   PubMed

9         Stock KP, Riemann JF, Stadler W, Rosch W. Tuberculosis of the pancreas. Endoscopy 1981; 13: 178-180   PubMed

10      Schneider A, Von Birgelen C, Duhrsen U, Gerken G, Runzi M. Two cases of pancreatic tuberculosis in      nonimmunocompromised patients. A diagnostic challenge and a rare cause of portal hypertension. Pancreatology      2002; 2: 69-73   PubMed

11      Franco-Paredes C, Leonard M, Jurado R, Blumberg HM, Smith RM. Tuberculosis of the pancreas: report of two cases      and review of the literature. Am J Med Sci 2002; 323: 54-58   PubMed

12      Woodfield JC, Windsor JA, Godfrey CC, Orr DA, Officer NM. Diagnosis and management of isolated pancreatic      tuberculosis: recent experience and literature review. ANZ J Surg 2004; 74: 368-371   PubMed

13      Ezratty A, Gumaste V, Rose E, Sachar DB, Tiscornia-Wasserman P. Pancreatic tuberculosis: a frequently fatal but      potentially curable disease. J Clin Gastroenterol 1990; 12: 74-77   PubMed

                       S- Editor  Liu Y    L- Editor  Negro F    E- Editor  Lu W

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