A 31-year-old male was referred to our gastroenterology department with a history of recurrent epigastric pain, nausea, and occasional vomiting since 6 months. Epigastric pain was characterized as intermittent, mild, and gnawing in character. The patient also noticed significant weight loss in 2 months. There was no history of fever and no past or family history of tuberculosis. The patient was nondiabetic. A chest X-ray, complete blood count, and liver and renal function tests were normal. ESR was 22 mm/hr. The patient had no known comorbidities and no history of hospitalization. Physical examination only revealed direct tenderness in the epigastrium. There was no lymphadenopathy. His HIV status was negative. Computed tomography scan of abdomen suggested thick antrum with dilated stomach, without any lymph node enlargement or ascites (Figure 1(b)). Upper GI endoscopy showed an irregular mass lesion at the antrum and pylorus region with narrowing of the lumen. (Figure 1(a)). The endoscope was passed beyond this point with difficulty. The impression then was gastric outlet obstruction with enlarged antrum with a possibility of antral malignancy. The patient underwent an endoscopic guided biopsy from the mass lesion. On histopathological examination, multiple epithelioid cell granulomas with Langhans-type giant cells and small foci of caseation necrosis were noted (Figures 1(c) and 1(d)).
As the clinical diagnosis of malignancy was high, the patient was again subjected to 2nd biopsy from multiple sites including a biopsy from the fundus and the duodenum. Tissue for PCR and culture for Mycobacterium tuberculosis was also taken in view of an earlier report. Histopathology showed a similar finding, and PCR for Mycobacterium tuberculosis was positive. The biopsy from the fundus and the duodenum showed normal morphology. A diagnosis of hypertrophic primary antral tuberculosis was made. The patient was put on antituberculous treatment (ATT) regimen consisting of Isoniazid 5 mg/kg, Rifampicin 10 mg/kg, Ethambutol 15 mg/kg, and Pyrazinamide 25 mg/kg body weight for the initial 2 months followed by Isoniazid and Rifampicin in the same dose for another 7 months. While on treatment, he gained weight and became symptom free. The repeat of the upper GI endoscopy after 4 months of treatment was suggestive of deformed but negotiable antrum. After a followup of 6 months, the patient was symptom free.