Diagnosis and differential diagnosis of pancreatic tuberculosis

doi:10.3969/j.issn.1004-583X.2023.10.006

Abstract

Abstract: Objective Pancreatic tuberculosis (PTB) is a rare type of tuberculosis, which is easily misdiagnosed as pancreatic neoplasms. The aim of this study is to discuss the key points of diagnosis and differential diagnosis of PTB. Methods Medical records of 23 patients with PTB diagnosed by biopsy from puncture or surgery from January 2012 to December 2021 in Peking Union Medical College Hospital were retrospectively reviewed. The pancreatic malignant tumor (PMT) patients matched by the admission date were selected as controls. Clinical and laboratory features were analyzed and compared between PTB and PMT patients. Results Among 23 patients with PTB, 15 (65.2%) were males. There mean age was (49±13) years. The predominant symptoms of PTB were abdominal pain (12/23, 52.2%), followed by weight loss (8/23, 34.8%) and fever (5/23, 21.7%). The level of C-reactive protein (CRP) in PTB group was significantly higher than that of PMT group (Z=-2.151, P=0.03). There were no significant differences in clinical features and other laboratory test findings between the two groups. The positive rate of Tuberculin skin test (TST) and enzyme-linked immunospot assay test (T-SPOT.TB) in PTB patients was 26.1% and 86.7%, respectively. The head of the pancreas was the most common involved site (12/23, 52.2%), and peripancreatic lymph node enlargement was revealed in 15 cases (65.2%). Peripancreatic lymph node enlargement was more common in PTB group (65.2% vs 30.0%, P=0.021), while dilatation of the pancreatic duct was more common in PMT group (50% vs 0, P<0.01). Among the 23 PTB patients, only 5 patients (21.7%) were bacteriologically diagnosed. Malignant tumor was considered as the first diagnosis in 15 PTB patients, and the misdiagnosis rate was as high as 65.2%. In 23 PTB patients, 14 (60.9%) and 9 cases (39.1%) received endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and surgery, respectively. Among the 14 PTB patients diagnosed by EUS-FNA, 6 patients were misdiagnosed as PMT at first and avoided unnecessary surgical resection. Conclusion It is difficult to distinguish PTB from pancreatic tumors based on clinical manifestations and laboratory tests. Tissue biopsy and bacteriological tests are key points for the diagnosis and differential diagnosis. PTB should be well concerned, and a timely examination of EUS-FNA is able to prevent unnecessary surgery.

Key words: tuberculosis, pancreas, diagnosis, pathology

CLC Number:

Liu Ye, Ruan Guiren, Liu Xiaoqing, Shi Xiaochun, Fei Guijun. Diagnosis and differential diagnosis of pancreatic tuberculosis[J]. Clinical Focus, 2023, 38(10): 898-903.

Add to citation manager EndNote|Ris|BibTeX

URL: https://huicui.hebmu.edu.cn/EN/10.3969/j.issn.1004-583X.2023.10.006

https://huicui.hebmu.edu.cn/EN/Y2023/V38/I10/898

Figures/Tables 4

Tab. 1 Comparison of clinical characteristics between groups

项目	PTB (n=23)	PMT (n=23)	统计值	P值
年龄(岁)	49±13	55±9	t=-1.797	0.079
性别[男,例(%)]	15(65.2)	15(65.2)	χ²=0	1
糖尿病[例(%)]	1(4.4)	5(21.7)	χ²=1.725	0.189
肺结核暴露史[例(%)]	3(13.0)	0(0.0)		0.233^*
既往结核病史[例(%)]	4(17.4)	0(0.0)		0.109^*
吸烟[例(%)]	6(26.1)	10(43.5)	χ²=1.533	0.216
饮酒[例(%)]	4(17.4)	7(30.4)	χ²=1.075	0.300
恶性肿瘤家族史[例(%)]	5(21.7)	6(26.1)	χ²=0.119	0.730
腹痛[例(%)]	12(52.2)	12(52.2)	χ²=0	1
发热[例(%)]	5(21.7)	2(8.7)	χ²=0.674	0.412
黄疸[例(%)]	2(8.7)	3(13.0)	χ²=0	1
腹部包块[例(%)]	1(4.4)	0(0.0)		1^*
体重下降[例(%)]	8(34.8)	8(34.8)	χ²=0	1
纳差[例(%)]	3(13.0)	3(13.0)	χ²=0	1
乏力[例(%)]	2(8.7)	3(13.0)	χ²=0	1

Tab. 2 Comparison of laboratory examination between groups

项目	PTB ( $n$ =23)	PMT ( $n$ =23)	统计量	$P$ 值
WBC(10⁹/L)	6.19±2.25	6.06±2.47	$t$ =0.191	0.849
Hb(g/L)	129.74±15.14	129.13±14.72	$t$ =0.138	0.891
PLT(10⁹/L)	223(153, 276)	206(173, 229)	$Z$ =-0.901	0.368
ALT(U/L)	20(12, 37)	19(13, 27)	$Z$ =-0.418	0.676
AST(U/L)	23.5(16.25, 31.75)	21(16.5, 26.5)	$Z$ =-0.209	0.834
GGT(U/L)	27(20.5, 95.5)	23(14.5, 37)	$Z$ =-1.279	0.201
ALP(U/L)	85.5(75, 140)	81(66.5, 101)	$Z$ =-1.044	0.297
TBIL(μmol/L)	10.8(7.3, 15.9)	11.5(7.8, 15)	$Z$ =0	1
DBIL(μmol/L)	3.3(2.5, 5.6)	3.9(2.9, 5.2)	$Z$ =-0.682	0.495
ALB(g/L)	41.91±4.46	40.09±4.54	t=1.376	0.176
Scr(μmol/L)	67.74±10.32	66.48±11.45	t=0.392	0.697
AMY(U/L)	106.7±219.25	102.21±70.50	t=0.085	0.933
LIP(U/L)	213.83±168.75	498.16±686.83	t=-1.75	0.095
CRP(mg/L)	5.09(3.09, 36.89)	1.62(0.60, 11.09)	$Z$ =-2.151	0.031
CEA(ng/ml)	2.05(1.20, 2.85)	2.5(1.82, 3.28)	$Z$ =-1.419	0.156
CA199(U/L)	12.25(7.85, 25.80)	19.90(8.07, 96.88)	$Z$ =-0.585	0.559
CA125(U/L)	14(10.5, 57)	10.35(7.7, 15.4)	$Z$ =-1.134	0.257

Tab. 2 Comparison of laboratory examination between groups

项目	PTB ( $n$ =23)	PMT ( $n$ =23)	统计量	$P$ 值
WBC(10⁹/L)	6.19±2.25	6.06±2.47	$t$ =0.191	0.849
Hb(g/L)	129.74±15.14	129.13±14.72	$t$ =0.138	0.891
PLT(10⁹/L)	223(153, 276)	206(173, 229)	$Z$ =-0.901	0.368
ALT(U/L)	20(12, 37)	19(13, 27)	$Z$ =-0.418	0.676
AST(U/L)	23.5(16.25, 31.75)	21(16.5, 26.5)	$Z$ =-0.209	0.834
GGT(U/L)	27(20.5, 95.5)	23(14.5, 37)	$Z$ =-1.279	0.201
ALP(U/L)	85.5(75, 140)	81(66.5, 101)	$Z$ =-1.044	0.297
TBIL(μmol/L)	10.8(7.3, 15.9)	11.5(7.8, 15)	$Z$ =0	1
DBIL(μmol/L)	3.3(2.5, 5.6)	3.9(2.9, 5.2)	$Z$ =-0.682	0.495
ALB(g/L)	41.91±4.46	40.09±4.54	t=1.376	0.176
Scr(μmol/L)	67.74±10.32	66.48±11.45	t=0.392	0.697
AMY(U/L)	106.7±219.25	102.21±70.50	t=0.085	0.933
LIP(U/L)	213.83±168.75	498.16±686.83	t=-1.75	0.095
CRP(mg/L)	5.09(3.09, 36.89)	1.62(0.60, 11.09)	$Z$ =-2.151	0.031
CEA(ng/ml)	2.05(1.20, 2.85)	2.5(1.82, 3.28)	$Z$ =-1.419	0.156
CA199(U/L)	12.25(7.85, 25.80)	19.90(8.07, 96.88)	$Z$ =-0.585	0.559
CA125(U/L)	14(10.5, 57)	10.35(7.7, 15.4)	$Z$ =-1.134	0.257

Tab. 3 Comparison of imaging performance between groups

项目	PTB (n=23)	PMT (n=23)	χ²值	P值
超声	14	14
病灶部位[例(%)]
胰头	9(64.3)	5(35.7)	2.286	0.131
胰颈	0(0.0)	2(14.3)		0.481*
胰体	2(14.3)	3(21.4)	0	1
胰尾	3(21.4)	4(28.6)	0	1
回声表现[例(%)]
囊性	2(14.3)	2(14.3)	0	1
实性	3(21.4)	3(21.4)	0	1
囊实性	5(35.7)	6(42.9)	0.15	0.699
未描述	4(28.6)	3(21.4)	0	1
胰周淋巴结肿大[例(%)]	4(28.6)	1(7.1)	0.974	0.324
CT	21	20
病灶部位[例(%)]
胰头	12(57.1)	5(25.0)	4.361	0.037
胰颈	1(4.8)	4(20.0)	1.026	0.311
胰体	4(19.1)	5(30.0)	0.666	0.414
胰尾	2(9.5)	7(35.0)	2.536	0.111
病变大小(cm)	3.7(2.95, 5.55)	3.4(2.1, 5.5)	0.223	0.825
占位表现[例(%)]
低密度	19(90.5)	16(80.0)	0.257	0.612
高密度	1(4.8)	2(10.5)	0.008	0.928
密度不均	7(33.3)	2(11.1)	1.59	0.207
增强CT[例(%)]	18	18
无明显强化	1(5.6)	5(27.8)	1.8	0.18
环形强化	2(11.1)	1(5.6)	0	1
非环形强化	15(83.3)	12(66.7)	0.593	0.441
胰周淋巴结肿大[例(%)]	14(66.7)	5(25)	7.152	0.007
胰管扩张[例(%)]	0(0)	10(50)		<0.01^*
病变部位^#[例(%)]	23	23
胰头	12(52.2)	7(30.4)	2.242	0.134
胰颈	1(4.3)	4(17.4)	0.898	0.343
胰体	5(21.7)	6(26.1)	0.119	0.73
胰尾	3(13.0)	8(34.8)	2.987	0.084
胰周淋巴结肿大	15(65.2)	6(30.0)	5.310	0.021

Tab. 4 PTB patients information confirmed through etiological diagnosis

序号	年龄/ 性别	组织获取方式	组织病原学		免疫学			组织病理学
序号	年龄/ 性别	组织获取方式	抗酸染色	分枝杆菌培养	PCR	PPD	T-SPOT.TB	上皮样肉芽肿	干酪样坏死	多核巨细胞
1	66/女	手术	+	+	/	-	+	+	-	+
2	27/男	穿刺	+	+	/	-	+	+	-	+
3	45/男	穿刺	-	-	+	+	+	+	-	+
4	50/男	穿刺	+	/	/	-	+	+	+	+
5	49/女	手术	+	/	/	-	/	+	-	-

References 18

[1]	World Health Organization. Grobal tuberculosis report 2022[R]. Geneva: World Health Organization, 2022.
[2]	Ray S, Das K, Ghosh R. Isolated pancreatic and peripancreatic nodal tuberculosis: A single-centre experience[J]. Trop Doct, 2021, 51(2):203-209. doi: 10.1177/0049475520962941 pmid: 33104450
[3]	Tosun S, Tosun A. Imaging of malignancy-suspected pancreatic involvement of extrapulmonary tuberculosis[J]. Turk J Gastroenterol, 2010, 21(1):54-59. pmid: 20533115
[4]	Auerbach O. Acute generalized miliary tuberculosis[J]. Am J Pathol, 1944, 20(1):121-136. pmid: 19970738
[5]	Paraf A, Ménager C, Texier J. La tuberculose du pancréas et la tuberculose des ganglions de l'étage supérieur de l'abdomen [Tuberculosis of the pancreas and tuberculosis of the lymph nodes of the upper region of the abdomen][J]. Rev Med Chir Mal Foie, 1966, 41(3):101-126. pmid: 5944700
[6]	Meesiri S. Pancreatic tuberculosis with acquired immunodeficiency syndrome: A case report and systematic review[J]. World J Gastroenterol, 2012, 18(7):720-726. doi: 10.3748/wjg.v18.i7.720 URL
[7]	Panic N, Maetzel H, Bulajic M, et al. Pancreatic tuberculosis: A systematic review of symptoms, diagnosis and treatment[J]. United European Gastroenterol J, 2020, 8(4):396-402. doi: 10.1177/2050640620902353 URL
[8]	Chaudhary P, Bhadana U, Arora MP. Pancreatic tuberculosis[J]. Indian J Surg, 2015, 77(6):517-524. doi: 10.1007/s12262-015-1318-4 pmid: 26884661
[9]	Agarwal S, Chaurasia Z, Malik DK, et al. The real burden of tuberculosis: hidden cases diagnosed on autopsy at a tertiary care center of India[J]. Int J Mycobacteriology, 2022, 11(1):47-50. doi: 10.4103/ijmy.ijmy_227_21 URL
[10]	Torres US, Matsumoto C, de Macedo Neto AC, et al. Common and uncommon benign pancreatic lesions mimicking malignancy: Imaging update and review[J]. Semin Ultrasound CT MR, 2018, 39(2):206-219. doi: S0887-2171(17)30111-7 pmid: 29571556
[11]	Nagar AM, Raut AA, Morani AC, et al. Pancreatic tuberculosis: A clinical and imaging review of 32 cases[J]. J Comput Assist Tomogr, 2009, 33(1):136-141. doi: 10.1097/RCT.0b013e31816c82bc pmid: 19188801
[12]	Xia F, Poon RT, Wang SG, et al. Tuberculosis of pancreas and peripancreatic lymph nodes in immunocompetent patients: experience from China[J]. World J Gastroenterol, 2003, 9(6):1361-1364. doi: 10.3748/wjg.v9.i6.1361 URL
[13]	Rana SS, Bhasin DK, Srinivasan R, et al. Distinctiveendoscopic ultrasound features of isolated pancreatic tuberculosis andrequirements for biliary stenting[J]. Clin Gastroenterol Hepatol, 2012, 10(3):323-325. doi: 10.1016/j.cgh.2011.10.018 URL
[14]	Santhosh S, Mittal BR, Bhasin D, et al. Role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in the characterization of pancreatic masses: experience from tropics[J]. J Gastroenterol Hepatol, 2013, 28(2):255-261. doi: 10.1111/jgh.2013.28.issue-2 URL
[15]	Shreve PD. Focal fluorine-18 fluorodeoxyglucose accumulation in inflammatory pancreatic disease[J]. Eur J Nucl Med, 1998, 25(3):259-264. doi: 10.1007/s002590050226 pmid: 9580859
[16]	Song TJ, Lee SS, Park DH, et al. Yield of EUS-guided FNA on the diagnosis of pancreatic/peripancreatic tuberculosis[J]. Gastrointest Endosc, 2009, 69(3 Pt 1):484-491. doi: 10.1016/j.gie.2008.10.007 pmid: 19231490
[17]	Chang KJ, Nguyen P, Erickson RA, et al. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma[J]. Gastrointest Endosc, 1997, 45(5):387-393. doi: 10.1016/s0016-5107(97)70149-4 pmid: 9165320
[18]	Varadarajulu S, Wallace MB. Applications of endoscopic ultrasonography in pancreatic cancer[J]. Cancer Control, 2004, 11(1):15-22. pmid: 14749619