A 33-year-old female presented with vague upper abdominal pain and dyspeptic symptoms for 2 months. She was otherwise well with no fever, constitutional symptoms, loss of appetite or loss of weight and was normoglycaemic. Her previous medical and surgical histories were unremarkable. She had no known allergies and her drug and psychosocial history was unremarkable. Her basic biochemistry, including liver enzymes were within normal limits. Her erythrocyte sedimentation rate was 13 mm in the first hour. She was investigated with a gastroduodenoscopy and an abdominal ultrasonography as her symptoms did not resolve with a trial of proton pump inhibitors. Her abdominal ultrasonography revealed a rounded 2.5 x 2.4 cm lesion in the head of the pancreas with low echogenic areas.
Magnetic resonance imaging scans revealed a well-demarcated exophytic lesion with multiple T2 high signals and small cystic areas in the anterior superior part of the head of the pancreas measuring 23 x 20 x 28 mm (Figure 1). Following a multidisciplinary team discussion, a decision was made to perform a laparotomy followed by enucleation of the lesion, or Whipple procedure. The diagnosis was a pancreatic cystic neoplasm. An endoscopic ultrasound was not performed due to nonavailability. The CA 19-9 was within normal limits.
She underwent a midline laparotomy and was found to have a well-defined exophytic firm to hard mass attached by a stalk to the upper border of the pancreatic head to the left of the hepatoduodenal ligament. The hepatic artery was densely adherent to the posterior surface of the mass. The mass was excised with a cuff of pancreatic tissue while carefully preserving the hepatic artery. Frozen section was not performed due to nonavailability in our institution. The postoperative period was uneventful.
The histology revealed granulomatous inflammation of a lymph node with caseation which was pathognomonic of tuberculosis (Figure 2). Unfortunately, specimen for TB culture was not sent as the diagnosis of TB was not suspected during surgery. Even though Zeihl-Neelsen staining was not performed on the specimen, TB PCR was performed in aspirated fluid of the surgical specimen, and it was positive. Chest X-ray was done following the diagnosis but was normal. She was started on category 1 anti-tuberculosis therapy, that is, quadruple anti-microbial therapy for 2 months followed by dual therapy with rifampicin and isoniazid for 4 months according to the local guidelines of management of extra-pulmonary TB.   At a follow up of 6 months, she was asymptomatic and further imaging was not performed.