Pancreatic tuberculosis: A case report and review of literature

Abstract

BACKGROUND

Pancreatic tuberculosis (TB) is a rare clinical condition that is frequently misdiagnosed. A definitive diagnosis is often established through surgical biopsy.

CASE SUMMARY

We report a previously healthy 21-year-old male who presented with epigastric pain and fever. Initially diagnosed with a pancreatic abscess and duodenal bulb perforation, the patient declined surgical intervention and was subsequently referred to our hospital. Abdominal computed tomography and endoscopy revealed a duodenal bulb perforation, esophageal and duodenal ulcers, and a mass in the pancreatic head. Endoscopic ultrasound with fine-needle aspiration identified a hypoechoic mass suggestive of TB. Cytological and histopathological analysis confirmed the diagnosis. The patient was diagnosed with primary pancreatic TB and started on anti-TB therapy. At the 1-year follow-up, the pancreatic mass had markedly regressed, and the patient had fully recovered with complete symptom resolution.

CONCLUSION

Pancreatic TB should be included in differential diagnosis; prompt endoscopic ultrasound-fine-needle aspiration and therapy enable recovery.

Key Words: Tuberculosis; Pancreas; Tumor; Fine-needle aspiration; Antituberculosis treatment; Case report

Core Tip: Pancreatic tuberculosis (TB) is a rare entity that is frequently misdiagnosed, often leading to unnecessary surgery. We report the case of a healthy 21-year-old patient initially suspected of having a pancreatic abscess, who was ultimately diagnosed with pancreatic TB via endoscopic ultrasound-guided fine-needle aspiration. The patient achieved full recovery after anti-TB treatment. This case highlights the importance of considering pancreatic TB in differential diagnosis to avoid invasive procedures, especially in young patients from TB-endemic areas.

INTRODUCTION

Pancreatic tuberculosis (TB) is a rare form of extrapulmonary TB, accounting for approximately 0.2%-2% of all TB cases worldwide[1,2]. The relative resistance of the pancreas to mycobacterial infection contributes to the rarity of this condition, which often poses diagnostic challenges[3]. Patients typically present with nonspecific symptoms, including epigastric pain, weight loss, and fever, which overlap with many gastrointestinal disorders. As a result, pancreatic TB is often misdiagnosed as pancreatitis, a pancreatic tumor, or a pancreatic abscess. Imaging studies, such as conventional computed tomography (CT) or magnetic resonance imaging, are generally unreliable in distinguishing pancreatic TB from other pancreatic masses, further complicating diagnosis. This report describes a case initially suspected to be a pancreatic abscess with duodenal bulb perforation, but ultimately diagnosed as primary pancreatic TB through endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). This report highlights the diagnostic complexity of pancreatic TB and offers practical insights into its clinical management, supported by a representative case and a systematic review of the literature.

CASE PRESENTATION

Chief complaints

A 21-year-old male presented with a 1-month history of recurrent epigastric pain, abdominal distension, and low-grade fever, with a maximum recorded temperature of 37.4 °C.

History of present illness

Initial evaluation at a local hospital suggested a pancreatic abscess. The patient was treated with antibiotics and gastroprotective therapy, but his symptoms persisted. Although a Whipple procedure (pancreaticoduodenectomy) was considered, the patient and his family chose to seek further evaluation at our institution.

History of past illness

The patient had no history of TB, hepatitis, smoking, or alcohol use.

Personal and family history

The patient had no chronic or familial inherited diseases.

Physical examination

Upon examination, his vital signs were stable. Mild tenderness was noted in the left upper quadrant, with no palpable hepatosplenomegaly.

Laboratory examinations

Laboratory tests revealed elevated liver enzymes, C-reactive protein, and pancreatic injury markers. Infectious disease screening for human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus was negative (Table 1). Contrast-enhanced CT showed multiple encapsulated air and fluid collections in the pancreatic head, measuring approximately 29.8 mm × 22.0 mm, likely connected to the duodenal bulb, with suspected ulcer perforation (Figure 1).

Figure 1 Abdominal contrast-enhanced computed tomography images. A: An irregular hypodense mass located in the duodenum and pancreatic head, measuring approximately 29.8 mm × 22.0 mm (orange box), with multiple internal air-fluid levels. The mass demonstrates peripheral contrast enhancement and indistinct surrounding fat planes, indicating local inflammatory infiltration or possible extension; B: Follow-up imaging shows a mildly hypodense mass in the duodenal-pancreatic head region, reduced in size compared to the prior scan (December 25, 2023). Previously observed gas and fluid components have been absorbed (orange box).

Table 1 Results of biochemical tests, inflammatory markers, and infectious disease screening after admission.

Parameter	Result (reference values)
Biochemical test
ALT, U/L	53 (9-50)
AST, U/L	20 (15-40)
ALP, U/L	132 (45-125)
GGT U/L	113 (10-71)
LPS, IU/L	66.6 (13.00-60.00)
p-AMY U/L	71 (15-53)
Inflammatory markers
CRP, mg/L	47.3 (< 1)
Infectious disease screening
HIV	Negative
HBV	Negative
HCV	Negative

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; GGT: Gamma-glutamyl transferase; LPS: Lipase; p-AMY: Ancreatic amylase; CRP: C-reactive protein; HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Imaging examinations

Gastroscopy revealed a duodenal bulb ulcer with perforation, an esophageal ulcer, and chronic superficial gastritis (Figure 2A and B). Chest CT indicated mild inflammation in the right upper lung. Despite initial treatment, the patient remained febrile, prompting a TB skin test, which returned strongly positive (> 20 mm), raising suspicion for pancreatic TB. EUS with FNA identified hypoechoic masses in both the esophageal wall and pancreatic head (Figure 3). Cytology revealed granulomatous inflammation (Figure 4A) with areas of central necrosis. Scattered mucinous epithelial cells with preserved differentiation were identified, along with fragmented lymphocytes, histiocytes, and cartilage components (Figure 4B). These findings, in combination with molecular diagnostic results, are consistent with TB-related pathological changes.

Figure 2 Gastroscopy examination. A: Duodenal bulb ulcer with perforation: A 0.6 cm ulcer with central depression is visible on the anterior wall of the duodenal bulb, with a fistulous opening at the base, scant purulent discharge, and surrounding mucosa exhibiting a coarse texture; B: Esophageal ulcer: A scar-like mucosal elevation is observed, along with a 0.4 cm ulceration featuring central depression and a white coating at the base.

Figure 3 Endoscopic ultrasound-fine needle aspiration images. Endoscopic ultrasound reveals a hypoechoic mass in the pancreatic head measuring approximately 29.8 mm × 22.0 mm (orange circle). Fine needle aspiration was performed for cytological and histopathological evaluation.

Figure 4 Histopathological examination. A: Granulomatous inflammation with central necrosis is observed in focal areas. Occasional mucinous epithelial cells with preserved differentiation are also identified (hematoxylin and eosin staining, magnification × 200); B: Microscopic examination showing scattered lymphocytes, histiocytes, and cartilage fragments (hematoxylin and eosin staining, magnification × 100).

FINAL DIAGNOSIS

Molecular diagnostics tests, including TB reverse transcription polymerase chain reaction and Mycobacterium TB gene detection, confirmed the pancreatic TB diagnosis(Table 2).

Table 2 Diagnostic methods and outcome in the present case.

Diagnostic method	Details	Outcome
Clinical presentation	Abdominal pain, weight loss, fever, jaundice, and anorexia	Nonspecific symptoms leading to initial misdiagnosis
Imaging (computed tomography/endoscopic ultrasound)	Imaging showed a pancreatic mass, suggestive of malignancy	Mass located in the head of the pancreas
Endoscopic ultrasound-guided fine needle aspiration	Biopsy performed to obtain esophageal tissue	Identified granulomas; supported tuberculosis diagnosis
Histopathological examination	Granulomas observed on biopsy; caseating necrosis suspected	Confirmed tuberculosis via granuloma presence
Molecular testing (PCR)	PCR testing for Mycobacterium tuberculosis performed	Positive result confirmed pancreatic tuberculosis diagnosis

PCR: Polymerase chain reaction.

TREATMENT

The patient was initially started on a triple anti-TB regimen consisting of isoniazid, rifampin, and ethambutol; however, his liver function deteriorated. This was attributed to bile duct compression by the pancreatic mass, leading to obstructive jaundice, which was confirmed by magnetic resonance cholangiopancreatography. The patient underwent percutaneous transhepatic biliary drainage combined with hepatoprotective therapy, resulting in improved liver function (Table 3). Following stabilization, anti-TB therapy was gradually reintroduced, starting with 750 mg ethambutol once daily. The regimen was then escalated to triple therapy comprising 300 mg isoniazid, 450 mg rifampin, and 500 mg ethambutol once daily. The patient was advised to continue this regimen after discharge with close follow-up.

Table 3 Liver function parameters following anti-tuberculosis treatment and subsequent hepatoprotective therapy.

Parameter	After anti-tuberculosis treatment initiation	Post-hepatoprotective treatment	After 1 month of treatment
ALT, U/L (9-50)	332	89	7
AST, U/L (15-40)	349	45	17
CB, μmol/L (≤ 6.89)	11.7	6.1	5.5
UCB, μmol/L (≤ 16.8)	7.3	3.0	11.2
ALP, U/L (45-125)	296	197	80
GGT, U/L (10-71)	484	142	35

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CB: Conjugated bilirubin; UCB: Unconjugated bilirubin; ALP: Alkaline phosphatase; GGT: Gamma-glutamyl transferase.

OUTCOME AND FOLLOW-UP

Post-treatment, the patient was closely monitored for clinical symptoms, liver function parameters, and pancreatic mass size. One month after discharge, liver function had returned to normal (Table 2). Throughout therapy, hepatic and renal function remained stable under regular surveillance. At the 1-year follow-up, contrast-enhanced CT revealed a mildly hypodense 7 mm mass in the duodenal-pancreatic head region, showing a significant size reduction compared to the prior scan (December 25, 2023; Figure 1). Follow-up endoscopy demonstrated scar-like changes in the mid-esophagus and ulcer-related scarring on the anterior wall of the duodenal bulb (Figure 5A and B).

Figure 5 Follow-up gastroscopy images. A: Scarring of the anterior wall of the duodenal bulb was observed, with surrounding mucosa appearing rough and granular; B: The esophagus shows ulcer-related scar formation, with smooth mucosa, a clearly visible vascular pattern, and good luminal distensibility.

DISCUSSION

TB remains one of the most significant infectious diseases globally. Although individuals of all age groups are susceptible, most cases occur in immunocompetent adults[4]. Approximately 98% of TB cases are reported in low- and middle-income countries, with increased vulnerability in individuals with immunodeficiency, diabetes, malnutrition, or a history of smoking[4]. The lungs are the most affected organ, accounting for approximately 80% of all TB cases. Extrapulmonary TB occurs in approximately 20% of all TB cases, often involving the lymph nodes, genitourinary tract, gastrointestinal system, and joints. Among these, abdominal TB accounts for approximately 10% of extrapulmonary cases[5,6].

We performed a literature review by searching PubMed and Google Scholar for case reports on pancreatic TB[4,6-82]. The search strategy included the following keywords: “primary pancreatic tuberculosis”, “pancreatic tuberculosis”, “pancreatic neoplasia”, combined with “case reports”, “case”, or “review”. Boolean operators (AND, OR) were applied as appropriate to refine and expand the search results. The inclusion criteria were as follows: (1) Articles providing complete patient information, including clinical presentation, diagnostic approach, treatment, and prognosis; (2) Case reports, case series, or reviews relevant to pancreatic TB or pancreatic neoplasia; and (3) Full-text availability. Exclusion criteria included articles lacking essential clinical data or those without sufficient diagnostic or therapeutic details. The primary search covered publications from January 2010 to July 2025. However, earlier studies were also included if they offered comprehensive and clinically relevant information deemed valuable for this review.

The mean age of onset for pancreatic TB was 41.12 ± 15.74 years, with a range of 11 to 86 years. The condition was more common in males (52, 56.5%) than in females (40, 43.5%). Most reported cases originated from Asia (47.8%), followed by Europe (19.6%) and Africa (18.5%). Fewer cases were reported from North America and New Zealand (7.6%) and South America (3.3%). Among the hospitalized patients, six tested positive for HIV and two had a prior history of TB (Table 3).

The most common clinical symptom of pancreatic TB was epigastric pain, reported in 73.9% of cases, followed by weight loss (51.1%), anorexia, nausea, or vomiting (35.9%), fever (32.6%), jaundice (17.4%), night sweats (9.8%), and fatigue (6.5%). These nonspecific symptoms contribute to diagnostic delays and often result in misdiagnoses. Imaging studies showed that pancreatic TB most involved the head of the pancreas (69.6%), followed by the body (18.5%), the tail (18.5%), and the neck (1.1%) (Table 4). Diagnosing pancreatic TB typically requires a combination of imaging, histopathological examination, and molecular biological tests. Although imaging studies can detect structural abnormalities, they are limited in distinguishing pancreatic TB from malignancies, as both conditions share overlapping radiological features[6].

Table 4 Demographics and symptoms in 92 patients diagnosed with pancreatic tuberculosis, n (%).

Variables	Value
Age, years	41.12 ± 15.74
Age range, years	11-86
Sex
Male	52 (56.5)
Female	40 (43.5)
Origin
Asia	44 (47.8)
Africa	17 (18.5)
Europe	18 (19.6)
North America and New Zealand	7 (7.6)
South America	3 (3.3)
HIV-positive	6 (6.5)
Previous tuberculosis	2 (2.2)
Symptoms
Fever	30 (32.6)
Epigastric pain	68 (73.9)
Night sweats	9 (9.8)
Weight loss	47 (51.1)
Jaundice	16 (17.4)
Fatigue	6 (6.5)
Anorexia/nausea/vomiting	33 (35.9)
Distribution
Pancreatic head	64 (69.6)
Pancreatic body	17 (18.5)
Pancreatic tail	12 (13.0)
Pancreatic neck	1 (1.1)

HIV: Human immunodeficiency virus.

Among the cases reviewed, the diagnostic methods included EUS-guided FNA in 42.4% of patients, CT-guided FNA in 12.0%, and exploratory laparotomy in 39.1% (Table 5). Once a definitive diagnosis of pancreatic TB was confirmed, most patients (84.8%) were treated with anti-tuberculous pharmacological therapy as first-line treatment. In 12.0% of cases, pancreatic surgery was performed first, with TB subsequently confirmed through pathological examination, prompting the initiation of anti-tuberculous therapy. Notably, two patients underwent surgical treatment alone without receiving pharmacological intervention (Table 6). Most patients exhibited symptomatic improvement following anti-tuberculous therapy. However, one patient developed secondary pulmonary TB after refusing medical treatment, and another, co-infected with HIV, succumbed to sepsis 5 months after beginning anti-tuberculous therapy (Table 7).

Table 5 Diagnostic modalities for pancreatic tuberculosis among the 92 reported cases, n (%).

Diagnostic modalities	Value
Endoscopic ultrasound-guided fine-needle aspiration	39 (42.4)
Computed tomography-guided fine-needle aspiration	11 (12.0)
Exploratory laparotomy	36 (39.1)

Table 6 Treatment modalities for patients with pancreatic tuberculosis, n (%).

Treatment	Value
Pharmacological	78 (84.8)
Surgical + pharmacological	11 (12.0)
Surgical	2 (2.2)

Table 7 Clinical outcomes of patients with pancreatic tuberculosis, n (%).

Outcome	Value
Cured	83 (90.2)
Secondary pulmonary tuberculosis	1 (1.1)
Died	1 (1.1)

Pancreatic TB is a rare form of extrapulmonary TB that presents significant diagnostic challenges due to its nonspecific clinical features and radiological similarities to pancreatic malignancies. Our literature review demonstrates that pancreatic TB predominantly affects young and middle-aged male patients, particularly in TB-endemic regions, especially in Asia and Africa. In these areas, the clinical presentation can be more heterogeneous and subtle, likely due to the high background prevalence of latent infections[82]. The most frequently reported clinical symptoms include epigastric pain, fever, and weight loss. Less common manifestations such as jaundice, anorexia, night sweats, and fatigue may also occur, though these nonspecific symptoms contribute to diagnostic delays and increase the risk of misdiagnosis.

A definitive pancreatic TB diagnosis generally requires histopathological and molecular confirmation. In our review, 42.2% of cases were diagnosed using EUS-FNA, 12.0% with CT-guided FNA, and 39.1% through exploratory laparotomy. Notably, more than half of the cases were confirmed using minimally invasive, non-surgical techniques, emphasizing the value of EUS-FNA as a preferred first-line diagnostic tool when available. Pancreatic TB can also present with elevated carbohydrate antigen 19-9 Levels[33,67], which may resemble those seen in pancreatic malignancies. Radiological features such as lesion calcification[52,77] and vascular involvement[52] can closely mimic the imaging characteristics of pancreatic cancer. Even with EUS, distinguishing between pancreatic TB and neoplastic lesions can be challenging[7]. This diagnostic uncertainty frequently leads to unnecessary surgical resections, increasing the risk of complications, delaying recovery, and imposing substantial financial and psychological burdens on patients.

Our findings highlight the importance of maintaining a high index of suspicion for pancreatic TB in patients presenting with pancreatic masses, especially in TB-endemic settings or among high-risk populations. A thorough diagnostic workup, including tissue sampling and molecular testing, is essential to avoid misdiagnosis and inappropriate surgical interventions. Once a pancreatic TB diagnosis is established, early initiation of anti-tuberculous therapy is crucial. According to the literature, most patients respond favorably to pharmacological treatment, showing significant clinical and radiologic improvement during follow-up.

CONCLUSION

The major challenge in managing pancreatic TB lies in achieving accurate and timely diagnosis. Clinicians must maintain a high index of suspicion, particularly in patients from TB-endemic regions who present with pancreatic masses. Early recognition and confirmation through histopathology and molecular testing are crucial for accurate diagnosis. Prompt initiation of anti-tuberculous therapy can significantly improve patient outcomes and prevent unnecessary surgical interventions.

ACKNOWLEDGEMENTS

We sincerely appreciate the patient and his family for their cooperation during information acquisition, treatment, and follow-up.