S1475 The Great Masquerade: Bladder Cancer in the Pancreas

Abstract

INTRODUCTION: Tuberculosis (TB) is a common disease in developing countries and is one of the leading causes of death in adults worldwide. The involvement of the pancreas alone is exceedingly rare. We report a case of an immunocompetent male who presents with fever, abdominal pain, weight loss, and was diagnosed with pancreatic TB. CASE DESCRIPTION/METHODS: A 32-year-old Ethiopian male with no past medical history presents with back and abdominal pain. He also reports fevers, chills, nausea, malaise, night sweats, and a 50lb weight loss within the last 7 months. His abdominal exam is benign. Previous tuberculin skin testing and HIV testing were negative. Magnetic resonance imaging reveals a multilobulated, solid, cystic lesion in the distal tail of the pancreas. Endoscopic ultrasound (EUS) confirms two hypoechoic lesions and a fine needle biopsy (FNB) establishes the diagnosis of tuberculosis. He is subsequently admitted for the treatment of extrapulmonary TB with quadruple therapy. DISCUSSION: Abdominal TB comprises 5% of all TB cases worldwide. Pancreatic TB is usually associated with widely disseminated TB in an immunocompromised host, making isolated pancreatic TB in an immunocompetent host exceedingly rare. The etiology of pancreatic TB is thought to occur via the lymphatic or hematogenous spread of the mycobacterium or reactivation of a prior TB infection. It can present with diverse symptoms and imaging findings are often nonspecific. On Computed Tomography, pancreatic TB may look like hypodense lesions with irregular borders, mostly found in the head and uncinate process of the pancreas. This can be mistaken for pancreatic malignancy. A biopsy of the lesion is the gold standard for diagnosis and will allow for microbiologic and pathologic confirmation. EUS is the preferred modality of imaging given the ability to assess the pancreatic lesion, evaluate lymphadenopathy, and obtain a sample with minimal concern for peritoneal seeding. Findings on biopsy include granulomatous, caseous necrosis with the presence of acid-fast bacilli. Treatment involves rifampin, isoniazid, pyrazinamide, and ethambutol for 6 months. The gold standard for diagnosis should be EUS with FNB, as it is the safest and least invasive approach to obtain a tissue diagnosis. Isolated pancreatic TB is a very rare form of TB that is difficult to diagnose, as the clinical manifestations are not specific and it requires a high clinical suspicion.