A 54-year-old female patient sought medical assistance due to abdominal pain, anorexia, hematochezia, postprandial fullness and an unexplained weight loss of 20 kg in the past three months. Four years previously, she had undergone orthotopic liver transplantation, but was not screened for latent tuberculosis infection prior to the procedure. Likewise, the patient did not undergo prophylaxis with isoniazid and had since been on immunosuppressive therapy with tacrolimus and mycophenolate, without experiencing acute graft rejection. Although the patient came from an endemic area for TB, she had no recollection of any prior exposure.
By reason of her persistent condition, she was admitted to the hospital's general surgery department. Upon admission, the patient underwent a computed tomography (CT) scan of the abdomen that identified a dilated pancreatic duct. This finding was later reiterated by a magnetic resonance cholangiopancreatography (MRCP) (Figure 1) which also detected an expansive pancreatic process (Figure 2).
Afterward, an esophagogastroduodenoscopy (EGD) was performed, detecting a vegetating lesion in the major duodenal papilla. Thus, a possible neoplasia in the pancreas with duodenal invasion was put forth. Subsequently, the patient underwent an exploratory laparotomy during which a tumor measuring approximately 6 cm was found in the head of the pancreas. The examination also revealed an infiltration in the hepatic hilum and duodenum, as well as ascites and secondary lesions in the jejunal loops. Biopsies from the liver, jejunum, and pancreas lesions were collected, and a Roux-en-Y gastrojejunoanastomosis was performed.
Histopathological analysis of the biopsied material revealed mild chronic liver disease with a biliary pattern in the liver injury, chronic atrophic pancreatitis without signs of malignancy in the pancreas lesions, and chronic inflammatory schistosomal fibrosing reaction, with the presence of numerous viable eggs of the parasite in the peritoneum jejunal lesions. Due to the finding of the schistosoma, the hospital's infectious disease department was consulted. A joint follow-up was started, and peritoneal schistosomiasis was treated with two doses of praziquantel 20 mg/kg.
As the pathology report ruled out any malignancy, a differential diagnosis of TB was proposed to justify the tumor in the pancreas. Hence, the patient was re-submitted to an EGD and a new biopsy of the pancreatic mass was collected. This sample was sent to GeneXpert testing for Mycobacterium tuberculosis. The exam yielded a positive result and characterized the bacteria as being sensitive to rifampicin. With this confirmation, treatment for TB was instituted, consisting of rifampicin, isoniazid, pyrazinamide and ethambutol. However, after seven days of treatment, the patient presented with dizziness, asthenia, jaundice and an elevation of transaminases. Therefore, pharmacological treatment was suspended and the patient was transferred to the infectious disease ward.
Following the suspension of treatment, transaminases and bilirubin levels decreased. Gradual reintroduction of the medication was attempted, but symptoms of hepatotoxicity resurfaced. Thus, treatment was changed to an alternative regimen consisting of ethambutol, moxifloxacin and amikacin. Unfortunately, the patient developed acute kidney injury secondary to amikacin use, and the medical staff opted for its suspension.
Even with the alternative regimen, the blood bilirubin levels remained elevated. Therefore, a new MRCP was requested to better evaluate the biliary and pancreatic duct, as well as the pancreatic mass. The exam displayed an increase in the pancreatic mass. After reviewing the results with the medical staff responsible for the care of the patient's liver transplant, it was decided upon performing a percutaneous biliary drainage. The procedure was carried out successfully.
Since the obstructive cause of the increased bilirubin and transaminase parameters was excluded following the mechanical drainage of the bile ducts, the initial pharmaceutical protocol was re-established. The patient responded well to treatment, with no further complications. For this reason, the patient was discharged and received a referral to follow-up the anti-tuberculosis treatment at a hospital in her hometown. In addition, she was asked to return a month later to the surgery department, as it would be necessary to reassess the inserted biliary catheter. Finally, the patient was recommended to undergo weekly exams for blood biochemistry assessment.