In 2014, a 76-year-old man with an approximately 26-year history of DM collapsed and was admitted to a community hospital with dehydration and a fever. His HbA1c (National Glycohemoglobin Standardization Program) level was 6.4%. The patient's mother, with whom he had lived for a long period during his youth, had once been successfully treated for pulmonary TB. Computed tomography (CT) was performed to investigate the cause of the fever and inadvertently revealed a 25-mm mass-like lesion in the pancreas head (Fig. 1). The patient was referred to our hospital for further examination. Contrast-enhanced CT revealed the lesion to be hypovascular. The lesion showed a high-intensity signal on diffusion magnetic resonance imaging (MRI) (Fig. 2). The serum levels of carcinoembryonic antigen (CEA), CA19-9, DUPAN-2, and SPAN-1 were all normal. Enlarged peripancreatic lymph nodes are often seen secondary to chronic liver diseases; however, the patient was negative for hepatitis B surface antigen, anti-hepatitis C virus antibody, and anti-HIV antibody. Gastrointestinal endoscopy and colonoscopy showed no evidence of advanced malignant tumors causing malignant lymphadenopathy. Using a 22-gauge fine-needle aspiration (FNA) needle (SonoTip(R) Pro Control; Medi-Globe GmbH, Achenmuhle, Germany), we performed endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the peripancreatic hypoechoic and heterogeneous lesion (Fig. 3). There were no abnormal signs, such as direct invasion or compression of the portal vein or common bile duct. Aspiration biopsy cytology via EUS-FNA was class II; a histological analysis revealed necrotic tissues without malignant cells or Langhans giant cells (Fig. 4).
On positron emission tomography (PET)-CT, there were the lesions with abnormal uptake of fluorodeoxy glucose (FDG)-PET in the left supra-clavicular lymph node and the peripancreatic lesion (Fig. 5). A whole biopsy of the left supra-clavicular lymph node was performed by an otolaryngologist, and a tuberculous granuloma with caseous necrosis was found (Fig. 6). Polymerase chain reaction (PCR) showed the granulomatous tissue to be positive for TB. PCR of the peripancreatic tissue obtained via EUS-FNA was also positive for TB (Fig. 7). Based on these findings, we made a diagnosis of tuberculous lymphadenitis, which was confirmed by a positive QuantiFERON test result. A follow-up examination after a 6-month course of treatment for extrapulmonary TB showed that the peripancreatic lymph node had decreased to approximately 10 mm in size.