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CASE REPORT
Year : 2003  |  Volume : 21  |  Issue : 1  |  Page : 61-62
 

Tubercular pancreatic abscess: A case report


Department of Microbiology, GB Pant Hospital, New Delhi - 110 002, India

Correspondence Address:
Department of Microbiology, GB Pant Hospital, New Delhi - 110 002, India

 ~ Abstract 

Primary involvement of the pancreas in bacterial and parasitic diseases is exceptional. Infection of the pancreas is usually secondary to necrosis and inflammation after serious necrotizing pancreatitis. Although a rare manifestation of a common disease, pancreatic tuberculosis can present to a clinician as a difficult diagnostic dilemma. The clinical manifestation may vary from painless obstructive jaundice to fever of unknown origin. Here, we report a case of pancreatic tuberculosis in a young alcoholic patient.

How to cite this article:
Lal R, Mishra B, Dogra V, Mandal A. Tubercular pancreatic abscess: A case report. Indian J Med Microbiol 2003;21:61-2


How to cite this URL:
Lal R, Mishra B, Dogra V, Mandal A. Tubercular pancreatic abscess: A case report. Indian J Med Microbiol [serial online] 2003 [cited 2019 Jun 15];21:61-2. Available from: http://www.ijmm.org/text.asp?2003/21/1/61/8315


Pancreatic abscess is an uncommon complication of acute and chronic pancreatitis, occurring in approximately 4% of cases.[1] The bacteria cultured from these abscesses are strains of  Escherichia More Details coli, Klebsiella spp., Enterobacter spp., Proteus spp., Pseudomonas spp., Streptococcus spp., Staphylococcus aureus   and less commonly Acinetobacter spp. Tuberculosis affecting pancreas remains a clinical rarity and therefore accurate and early diagnosis, prompt operative therapy along with the institution of proper antibiotic therapy are essential in reducing the morbidity and mortality in patients with such complications.

 ~ Case reports Top

A 21 year old male, known alcoholic for last ten years, was admitted with pain abdomen, fever and constipation for past three days. The patient had an acute onset of pain twenty days previously, initially localized to the epigastric region and then spreading to whole of the abdomen. The pain was severe in nature and was associated with 4-5 episodes of vomiting. Pain continued for 36 hours and then abated after taking some medication. There was no history of radiation of pain to the back or relief in pain in particular posture. Since then patient had been having dull aching pain with remissions in between with aggravation of pain for the past three days for which he was brought to the hospital. There was no history of any trauma to abdomen or chronic liver disease in the form of pedal edema or ascites.
Per abdominal examination revealed a firm lump in the epigastric region, which was tender on palpation. Blood test showed the white blood count as 8,400/mm,[3] ESR as raised (40mm/hour) and serum amylase was 100u/100mL. Chest x- ray was normal. The patient was admitted as a case of acute abdomen which after full investigation (including radiological) was diagnosed as a case of pancreatic abscess.
Ultrasonography of abdomen revealed hypoechoic pancreas with enlargement of head and body with evidence of a cystic lesion of size 36x37 mm along with pancreatic and peripancreatic lymphadenopathy. Liver was mildly echogenic suggestive of mild fatty infiltration.
A contrast enhanced computed tomography showed pancreas appearing bulky with evidence of hypodense non enhancing areas. Multiple enlarged lymph nodes of variable size at peripancreatic and pancreatic region were noticed. The patient was radiologically diagnosed as acute pancreatitis with peripancreatic lymphadenopathy with mild fatty infiltrate of liver.
Ultrasound guided aspiration of the cystic lesion in the pancreatic head and body was done and about 1.5mL of thick, viscous fluid was aspirated. Gram stain of the aspirate revealed numerous pus cells but no organism. Culture of the aspirate for aerobic and anaerobic bacteria was found to be sterile. Ziehl -Neelsen stain demonstrated acid fast bacilli which on culture were biochemically confirmed to be Mycobacterium tuberculosis, indicating pancreatic tuberculosis. The patient was placed on isoniazid 300 mg, rifampin 600 mg, pyrazinamide 1500 mg and ethambutol 1000 mg per day. The patient showed improvement after initiation of therapy and was discharged after one week to follow up as an outpatient at a later date.
The patient was seen as an outpatient two weeks later and had remained afebrile without any complaints. He has since been lost to follow up.

 ~ Discussion Top

Abdominal infection with tuberculosis commonly affects the spleen liver and the ileocaecal region. Pancreatic tuberculosis is quite unusual. For example, Auerbach[2] reported pancreatic involvement in only 4.7% of 297 autopsy cases of military tuberculosis. The current case is unique in that it documents tuberculosis as the cause of pancreatic abscess. We speculate that the tubercle bacilli reached the pancreas in our patient as a result of lymphohematogenous dissemination. It remains unclear, however, why the pancreas would become a site of reactivation of tuberculosis. It is possible that alcoholism of ten years duration might have altered the pancreas in such a way as to promote the growth of tubercule bacilli.[3]
Tuberculosis of pancreas has been reported to present with anorexia, weight loss, low grade fever, abdominal mass, pancreatic abscess, obstructive jaundice, acute or chronic pancreatitis, GI haemorrhage and splenic artery thrombosis.[4],[5],[6] Our patient presented with pain in abdomen, low grade fever and abdominal mass. Therefore, tuberculous involvement of the pancreas should be a consideration in any young alcoholic patient presenting with a mass in the pancreas in the setting of a febrile illness.
Standard antitubercular therapy appears to successfully treat pancreatic tuberculosis.[7] External drainage of the abscess may rarely be necessary, but there is as yet no published experience with percutaneous drainage alone.8 Therefore, evaluation of a pancreatic mass in a susceptible patient should also include smear for acid fast bacilli and culture of pancreatic tissue and aspirate besides ultrasound and CT scan of the abdomen.  

 ~ References Top

1.Warshaw AL. Current concepts in pancreatic abscesses. N Engl J Med 1972;287:1234-1236.  Back to cited text no. 1    
2.Auerbach O. Acute generalized miliary tuberculosis. Am J Pathol 1944;20:121-136.   Back to cited text no. 2    
3.Stambler JB, Klibaner MI, Bliss CM, Lamont JT. Gastroenterol 1982;83:922-925.  Back to cited text no. 3    
4.Shukla HS, Hughes LE. Abdominal tuberculosis in 1970s: A continuing problem. Br J Surg 1978;65:403-405.  Back to cited text no. 4    
5.Chandrashekhara KL, Kota L, Iyer S, Stanek A, Herbstman H. Pancreatic tuberculosis mimicking carcinoma. Gastrointest endosc 1985;31:386-388.  Back to cited text no. 5    
6.Stock KP, Riemann JH, Stadler W, Rosch W. Tuberculosis of pancreas. Endoscopy 1981;13:178-180.  Back to cited text no. 6    
7.Levine R, Tenner S, Steinberg W, Ginsberg A, Borum M, Huntington D. Tuberculous Abscess of the pancreas. Dig Dis And Sci 1992;37(7):1141-1144.  Back to cited text no. 7    
8.Elizondo ME, Arratibel JAA, Compton CC, Warshaw AL. Surgery 2001;129(1):114-116.   Back to cited text no. 8    
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2004 - Indian Journal of Medical Microbiology
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