Tuberculous Pancreatic and Liver Abscesses Presenting as Obstructive Jaundice in an Immunocompetent Patient

Abstract

Isolated hepatobiliary, pancreatic, and peripancreatic tuberculosis (TB) is an extremely rare disease, particularly in immunocompetent individuals. To the best of our knowledge, the presentation of combined pancreatic and liver abscesses is a particularly uncommon presentation among the reported cases in the literature. This presents a significant challenge in clinical diagnosis. In this report, we discuss the case of a 24-year-old Nepalese man who presented with epigastric pain and jaundice. Further, tuberculous pancreatic and liver abscesses were detected by abdominal CT and MRI, which were later confirmed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with pus smear and polymerase chain reaction (PCR) test. These tests were positive for acid-fast bacilli (Mycobacterium tuberculosis). The patient responded well to anti-tubercular therapy (ATT). As the clinical presentation is often unclear and radiological imaging may be misleading, physicians should have a high index of suspicion for TB, especially if the patient is young and belongs to an area highly endemic for TB.

Keywords: abdominal tuberculosis; anti-tubercular therapy (att); intra-abdominal abscess; liver abscess; pancreatic abscess.

Figure 1. Selected axial ultrasound images of the upper abdomen

(a) A heterogeneously echoic lesion with multiple cystic areas was noted in the region of the pancreatic head with peripheral vascularity (4.3 × 3.9 cm). (b) A mild degree of intrahepatic biliary radicles

Figure 2. Axial images of contrast-enhanced CT of the abdomen

A well-defined lobulated hypodense lesion with rim enhancement involving the pancreatic head, caudate lobe, and peripancreatic lymph nodes exerting mass effect seen as dilatation of the hepatic ducts, common bile duct, and pancreatic duct as well as compression of the portal vein and inferior vena cava with no thrombus formation CT: computed tomography