Dados do Trabalho

Título

AN EXTRAPULMONARY TUBERCULOSIS CASE WITH ISOLATED PANCREATIC AND LIVER INVOLVEMENT SIMULATING A PANCREATIC TUMOR IN A YOUNG IMMUNOCOMPETENT PATIENT

Descrição sucinta do(s) objetivo(s)

•To present an unusual case of extrapulmonary isolated pancreatic and liver tuberculosis in a young immunocompetent patient.
•To describe the most frequent imaging findings of pancreatic and liver tuberculosis.
•To mention the most important radiological differential diagnosis of pancreatic and liver tuberculosis, and the features that might favor its diagnosis.

História clínica

A 29-year-old male patient without previous diseases presented to our institution with a subacute history of abdominal pain and weight loss. Contrast enhanced computed tomography and magnetic resonance imaging studies revealed an ill-defined heterogeneous lesion with restricted diffusion localized in the pancreatic neck with extension to the liver’s caudate lobe. Mass effect over the hilar vessels of the liver, enlarged lymph nodes and surrounding fat stranding were also observed. A pancreatic tumor was initially considered but normal levels of tumoral markers were noted. An endoscopy with transgastric biopsies of the lesion showed granulomatous tissue with Langhans giant cells. Lastly, molecular analysis detected rifampicin resistant Mycobacterium tuberculosis genes. Tests results for lung tuberculosis and immunodeficiency disorders were negative.

Discussão e diagnóstico

Cases of isolated pancreatic and liver tuberculosis are extremely rare, particularly in immunocompetent patients and in the absence of lung tuberculosis. Their radiological findings are variable, most frequently presenting as hepatomegaly, micronodular miliary lesions, tubercular abscess and a macronodular form that can simulate malignancy. Other radiological differential diagnoses of the macronodular form include fungal abscess, sarcoidosis and autoimmune pancreatitis.
In this case, a malignant pancreatic neck tumor extending to the liver was first considered. Even though the lesion showed mass effect over the hilar vessels of the liver and other features suggestive of malignancy, the diagnosis was uncertain based on the patient's age, the integrity of the remaining pancreas parenchyma and the absence of common bile and pancreatic ducts dilatation. Even more, the presence of multiple enlarged lymph nodes (some of them showing central necrosis) made the diagnosis of granulomatous disease more likely, which was lastly confirmed.

Conclusões

Extrapulmonar tuberculosis with isolated pancreatic and liver involvement cases are rare and can simulate a pancreatic tumor. However, certain radiologic features might favor its diagnosis, which is ultimately made by microbiological and molecular tests.

Palavras Chave

Mycobacterium não tuberculosis; CANCER

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