Clinical Case Summary

A 50-year-old man with known hypertension and hypothyroidism was recently diagnosed with AML. He presented with high-grade fever for one month. There were no gastrointestinal complaints, weight loss, or night sweats. Physical examination was unremarkable aside from fever (38.7°C); he was hemodynamically stable.
Initial labs revealed pancytopenia: hemoglobin 8.4 g/dL, WBC 1.2 × 10⁹/L, platelets 42 × 10⁹/L, and ANC 200/µL. Peripheral smear confirmed febrile neutropenia. He was started on intravenous broad-spectrum antibiotics. Due to persistent fever, a workup for occult infections was initiated. Blood and urine cultures were negative. Serum and BAL galactomannan were positive, suggesting possible invasive aspergillosis; liposomal amphotericin B was commenced.
Abdominal ultrasound revealed a bulky pancreas with heterogeneous echotexture. Contrast-enhanced CT showed a 2×3 cm heterogeneously enhancing lesion in the pancreatic tail. CA 19-9 was normal. EUS identified a hypoechoic.The main differentials considered included: Leukemic infiltration: due to AML background, Primary pancreatic malignancy: suggested by the imaging appearance, Invasive fungal infection: supported by positive galactomannan assays,Pancreatic tuberculosis: rare, but considered due to an endemic background.
FNAC showed granulomatous inflammation with caseation. GeneXpert MTB/RIF was positive for M. tuberculosis.
He was started on anti-tubercular therapy. Fever resolved within 10 days. Imaging at 3 months showed resolution of the mass. He completed a 6-month course uneventfully.
The presence of a discrete mass and lack of gastrointestinal symptoms complicated the diagnosis. FNAC with GeneXpert was key in confirming TB and ruling out other causes.

References

Pancreatic TB is a rare form of extrapulmonary tuberculosis, accounting for less than 5% of abdominal TB cases. It typically affects younger individuals and may be more prevalent in immunocompromised patients, including those with HIV or malignancy.

Clinically, pancreatic TB is a great mimicker. Common symptoms include fever, abdominal pain, weight loss, and night sweats. Jaundice may be seen if there is biliary involvement. Radiologically, it is difficult to distinguish from pancreatic cancer or pancreatitis. Masses may be solid or cystic and can involve any part of the pancreas.

EUS has emerged as a critical tool in evaluating pancreatic lesions. It allows for high-resolution imaging and real-time sampling via FNAC. Cytological examination may reveal granulomatous inflammation, although this is not pathognomonic. A definitive diagnosis often hinges on demonstration of acid-fast bacilli, culture, or PCR-based methods such as GeneXpert.

Our case highlights the importance of considering TB in the differential diagnosis of pancreatic masses, especially in endemic areas or immunocompromised patients. Early diagnosis via EUS-FNA and initiation of ATT can result in complete clinical and radiological recovery, sparing the patient from unnecessary surgical intervention.