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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.110 no.7 Madrid jul. 2018

http://dx.doi.org/10.17235/reed.2018.5527/2018 

SCIENTIFIC LETTERS

A study of a pancreatic mass: not all is what it seems

Irene Andaluz-García1  , Cristina Suárez-Ferrer1  , Pedro Mora-Sanz1 

1Servicio de Aparato Digestivo. Hospital Universitario La Paz. Madrid, España

Key words: Acute cholangitis; Endoultrasonography; Pancreatic tuberculosis

Dear Editor,

A 48-year-old Ecuatorian male with no previous medical history was admitted to hospital due to acute cholangitis and wasting syndrome of a three-week duration. An abdominal ultrasound and a subsequent abdominal computed tomography (CT) identified a hypoattenuating nodule with a cyst-like appearance in the pancreatic head. The differential diagnosis was either an adenocarcinoma with a necrotic component or a cystic neoplasm. Thus, an endoultrasonography with fine needle aspiration (FNA) was performed (Fig. 1), which revealed an inflammatory granulomatous process with necrosis, giant cells, reactive plasmocytosis and neovascularization. After antibiotic therapy, the cholangitis was resolved and the laboratory tests normalized. However, the patient started to present a persistent fever, neurological and urological symptoms. The patient was finally diagnosed with disseminated tuberculosis (TB) with pancreatic involvement after a complete study with a mycobacterial culture in different media.

Fig. 1 A 20 mm hypoechoic mass in relation to the surrounding parenchyma in pancreatic head, causing an abrupt stoppage of the bile duct, can be observed. It is in intimate contact with the upper mesenteric vein in the confluence of the splenoportal axis without thrombose; it is difficult to rule out infiltration at this location. 

Discussion

Pancreatic tuberculosis is a very uncommon condition that usually occurs in context of disseminated TB 1,2. An infection of pancreas can result from hematogenous or lymphatic spread or by reactivation of a previously latent form 3. Diagnosis is a challenge as the symptoms can present as acute or chronic pancreatitis, pancreatic abscess, obstructive jaundice or an isolated pancreatic mass mimicking a neoplasm, as in this case 1. Furthermore, there are no pathognomonic findings on imaging; therefore, pathological and/or microbiological confirmation is required 4. In cases of a pancreatic mass and an unexplained fever, TB is a possibility that should be considered in order to start targeted therapy as soon as possible.

Bibliografía

1. García del Olmo N, Boscà Robledo A, Penalba Palmí R, et al. Tuberculosis ganglionar peripancreática primaria como diagnóstico diferencial de neoplasia pancreática. Rev Esp Enferm Dig 2017;109(7):528-30. DOI: 10.17235/reed.2017.4811/2016 [ Links ]

2. Barquilla-Cordero P, Chiquero-Palomo M, Martín-Noguerol E, et al. Primary pancreatic tuberculosis in an immunocompetent patient: first case report in Spain. Gastroenterol Hepatol 2010;33:582-5. DOI: 10.1016/j.gastrohep.2010.06.002 [ Links ]

3. Raghavan P, Rajan D. Isolated pancreatic tuberculosis mimicking malignancy in an immunocompetent host. Case Rep Med 2012;2012:501246. DOI: 10.1155/2012/501246 [ Links ]

4. Zacharia GS, Antony R, Kolassery S, et al. Isolated pancreatic tuberculosis masquerading as pancreatic cancer. Gastroenterol Rep (Oxf) 2014;2:154-7. DOI: 10.1093/gastro/gou017 [ Links ]