1990, The British Journal of Radiology, 63, 981-982
Case of the month An unusual cause of abdominal pain By J. Wong-You-Cheong, BSc, MBChB, MRCP Department of Diagnostic Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL {Received October 1989 and in revised form February 1990)
A 57-year-old Asian woman presented with general malaise and intermittent pyrexia 3 months after a renal transplant. She was immunosuppressed with Cyclosporin A. Examination revealed low grade fever and tenderness in the upper abdomen; chest and abdominal radiographs were unremarkable. An ultrasound scan was performed, which showed a heterogeneous mass in the region of the head of the pancreas, displacing the superior mesenteric vein and compressing the inferior vena cava. There was no biliary dilatation. Computed tomographic (CT) scans of the abdomen
were then obtained with intravenous contrast enhancement (Fig. 1), followed by endoscopic retrograde pancreatography (ERP) (Fig. 2). What are the abnormalities and what is the differential diagnosis?
Address for correspondence: Department of Diagnostic Radiology, North Manchester General Hospital, Crumpsall, Manchester M8 6RB.
Figure 1. Computed tomographic scan of upper abdomen with intravenous contrast enhancement.
Vol. 63, No. 756
Figure 2. Endoscopic retrograde pancreatogram.
981
Case of the month
Computed tomography confirms the presence of a heterogeneous, enhancing, hypodense mass in the head of the pancreas with displacement and compression of vessels as seen on ultrasound. On ERP the main pancreatic duct is occluded and the proximal side branches are disorganized with abnormal stenoses and beading. The main diagnoses are pancreatic carcinoma and chronic pancreatitis. The patient underwent laparotomy where a hard mass was found in the pancreatic head causing obstruction to the duodenum. The mass was inseparable from the superior mesenteric vein and was thought to be an inoperable pancreatic carcinoma. A gastrojejunostomy and two Tru-cut biopsies were performed. There was no evidence of neoplasm in the biopsy samples but caseating granulomata were present, and a Ziehl-Neelsen stain was positive. The patient received antituberculous therapy and a follow-up ultrasound scan showed no evidence of a residual mass. The patient remains well on follow-up 4 years later.
two different mechanisms: haematogenous dissemination or by penetration of the organ by adjacent lymph nodes. This patient had no other evidence of tuberculosis, but she had been immunosuppressed and she was of Asian origin. Tuberculosis is well recognized in transplanted patients in whom the presentation is atypical and diagnosis is difficult. Infection is predominantly pulmonary (McWhinney et al, 1981) and responds well to antituberculous therapy. Involvement of the pancreas, as in this case, is unusual. A computerized literature search failed to reveal a similar case in the English literature in the last 15 years. The diagnosis of pancreatic tuberculosis is difficult. Clinical features may suggest the possibility, which should be investigated by CT and ERP; confirmation, however, must be histological. Acknowledgment I wish to thank Mr R. W. G. Johnson for permission to report this case.
Discussion
References
Tuberculosis of the pancreas is rare even in countries where tuberculosis is endemic. Involvement of the pancreas can occur as part of a generalized infection such as miliary tuberculosis. Focal involvement is rarer still. Tuberculosis may present as acute or chronic pancreatitis (Stock et al, 1981) and as a mass mimicking carcinoma (Chandrasekhara et al, 1985). It has been postulated that infection of the pancreas may occur by
CHANDRASEKHARA, K.
982
L.,
IYER, S.
K.,
STANEK, A.
E.
&
HERBSTMAN, H., 1985. Pancreatic tuberculosis mimicking carcinoma. Gastrointestinal Endoscopy, 31, 386-388. MCWHINNEY,
N.,
KHAN,
O.
&
WILLIAMS,
G.,
1981.
Tuberculosis in patients undergoing maintenance haemodialysis and renal transplantation. British Journal of Surgery, 68, 408-411. STOCK, K. P., RIEMANN, J. F., STADLER, W. & ROSCH, W.,
1981.
Tuberculosis of the pancreas. Endoscopy, 13, 178-180.
The British Journal of Radiology, December 1990
Case of the month An unusual cause of abdominal pain By J. Wong-You-Cheong, BSc, MBChB, MRCP Department of Diagnostic Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL {Received October 1989 and in revised form February 1990)
A 57-year-old Asian woman presented with general malaise and intermittent pyrexia 3 months after a renal transplant. She was immunosuppressed with Cyclosporin A. Examination revealed low grade fever and tenderness in the upper abdomen; chest and abdominal radiographs were unremarkable. An ultrasound scan was performed, which showed a heterogeneous mass in the region of the head of the pancreas, displacing the superior mesenteric vein and compressing the inferior vena cava. There was no biliary dilatation. Computed tomographic (CT) scans of the abdomen
were then obtained with intravenous contrast enhancement (Fig. 1), followed by endoscopic retrograde pancreatography (ERP) (Fig. 2). What are the abnormalities and what is the differential diagnosis?
Address for correspondence: Department of Diagnostic Radiology, North Manchester General Hospital, Crumpsall, Manchester M8 6RB.
Figure 1. Computed tomographic scan of upper abdomen with intravenous contrast enhancement.
Vol. 63, No. 756
Figure 2. Endoscopic retrograde pancreatogram.
981
Case of the month
Computed tomography confirms the presence of a heterogeneous, enhancing, hypodense mass in the head of the pancreas with displacement and compression of vessels as seen on ultrasound. On ERP the main pancreatic duct is occluded and the proximal side branches are disorganized with abnormal stenoses and beading. The main diagnoses are pancreatic carcinoma and chronic pancreatitis. The patient underwent laparotomy where a hard mass was found in the pancreatic head causing obstruction to the duodenum. The mass was inseparable from the superior mesenteric vein and was thought to be an inoperable pancreatic carcinoma. A gastrojejunostomy and two Tru-cut biopsies were performed. There was no evidence of neoplasm in the biopsy samples but caseating granulomata were present, and a Ziehl-Neelsen stain was positive. The patient received antituberculous therapy and a follow-up ultrasound scan showed no evidence of a residual mass. The patient remains well on follow-up 4 years later.
two different mechanisms: haematogenous dissemination or by penetration of the organ by adjacent lymph nodes. This patient had no other evidence of tuberculosis, but she had been immunosuppressed and she was of Asian origin. Tuberculosis is well recognized in transplanted patients in whom the presentation is atypical and diagnosis is difficult. Infection is predominantly pulmonary (McWhinney et al, 1981) and responds well to antituberculous therapy. Involvement of the pancreas, as in this case, is unusual. A computerized literature search failed to reveal a similar case in the English literature in the last 15 years. The diagnosis of pancreatic tuberculosis is difficult. Clinical features may suggest the possibility, which should be investigated by CT and ERP; confirmation, however, must be histological. Acknowledgment I wish to thank Mr R. W. G. Johnson for permission to report this case.
Discussion
References
Tuberculosis of the pancreas is rare even in countries where tuberculosis is endemic. Involvement of the pancreas can occur as part of a generalized infection such as miliary tuberculosis. Focal involvement is rarer still. Tuberculosis may present as acute or chronic pancreatitis (Stock et al, 1981) and as a mass mimicking carcinoma (Chandrasekhara et al, 1985). It has been postulated that infection of the pancreas may occur by
CHANDRASEKHARA, K.
982
L.,
IYER, S.
K.,
STANEK, A.
E.
&
HERBSTMAN, H., 1985. Pancreatic tuberculosis mimicking carcinoma. Gastrointestinal Endoscopy, 31, 386-388. MCWHINNEY,
N.,
KHAN,
O.
&
WILLIAMS,
G.,
1981.
Tuberculosis in patients undergoing maintenance haemodialysis and renal transplantation. British Journal of Surgery, 68, 408-411. STOCK, K. P., RIEMANN, J. F., STADLER, W. & ROSCH, W.,
1981.
Tuberculosis of the pancreas. Endoscopy, 13, 178-180.
The British Journal of Radiology, December 1990
