In March 2016, a 23-year-old young man was admitted to our hospital with main complaint of abdominal pain and nausea after diet as well as loss of appetite for half a month. The vague abdominal pain or discomfort was predominantly in the epigastrium. Meanwhile, the concomitant symptoms did not include fever, night sweat, reflux, heartburn, vomiting, haematemesis, and melena. Physical examination was unremarkable except for mild tenderness over the upper abdomen. The patient's medical history pointed out that he did not have any special diseases and had not been previously diagnosed as thoracic TB or other organ's TB. Other than that, it should be noted that the patient had lost 6 pounds of weight just only half a month.
The blood routine test and the function of liver and kidneys were all within normal range. The serological tests for HBV, HCV, HIV, and syphilis were all negative. Carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA19-9) were both not elevated. Electronic gastroscope showed that there was a mucosal protrusion at duodenal bulb with an ulcerated surface in the center, coated with whitish fur. Narrow band imaging (NBI) and magnifying endoscope (ME) showed that the local vascular was disordered and gland duct disappeared. Endoscopic ultrasonography (EUS) showed that the duodenal bulb contained hypoechoic mass on the top of the raised center. The echo inside was uniform but the duodenal wall lacked unity and coherence. The lesion was closely adjacent to the serosa (Figure 1). The gastroscope biopsy displayed an inflammation in duodenal mucosa and low-grade atypical hyperplasia in some glands (data not shown). Computed tomography (CT) showed an irregular low density lesion in the neck of the pancreas, with unclear margins of size 3.7 x 4.5 cm that enhanced after iodinated contrast material. Hepatic hilar region and intrahepatic cholangiectasis were both found. CT images also revealed that the arteria hepatica was enveloped which mimicked a pancreatic head carcinoma (Figure 2). Magnetic resonance imaging (MRI) revealed enlarged pancreatic head and neck, long T1/T2 signal, and high DW1 signal. Furthermore, common bile duct was constricted by pancreatic mass, resulting in dilated bile duct of liver inside and outside. The contrast enhanced MRI had heterogeneous density, with the vascular involvement; therefore, the neoplastic changes should be strongly considered (Figure 3). Besides these, we also give the patient the chest X-ray to approve or eliminate the possibility of primary tuberculosis. The result showed that there was no abnormality found in chest X-ray (data not shown).
According to the illness history and plenty of examinations above, although the vascular involvement supported the diagnosis of malignant tumor, other examinations did not show any surgical contraindication, and the patient was a young man, and his families had strong treatment preferences. To clarify the disease, only through surgery can doctors obtain the tissues to do pathological diagnosis. For this reason, we ultimately gave the patient exploratory laparotomy under general anesthesia. Intraoperative findings were as follows: the lesion located in the pancreatic head, 6 x 5 x 3 cm in size, which had an obscure boundary and hard texture. The gallbladder was not large, choledochectasia and the portal vein were invaded, and multiple enlarged lymph nodes around pancreas and the fifth groups of stomach were seen and touched. Therefore, the pancreas and duodenum were resected using Whipple procedure (pancreatoduodenectomy). Histopathologic specimens returned as follows: (1) the granuloma, which was comprised of lymphocyte, epithelioid cell, and polykaryocyte, could be seen in the multiple nodules and fibrous adipose tissues between the junctions of the pancreatic head and duodenum. The caseous necrosis appeared frequently in the center of several granulomas. These features are diagnostic criteria for tubercular nodules. (2) The portal vein was composed of smooth muscle, in which lymphocyte and a little number of polykaryocytes infiltrated. (3) Tubercular nodules were seen in the lymph nodes of intestinal adipose tissues. (4) Individual caseating granulomatous inflammation and necrosis were found in the omentum of lesser curvature of stomach. (5) Many lymph nodes isolated from operation displayed the pathological characteristics of tuberculosis (Figure 4). The patient was thereafter advised to transfer to the Intensive Care Unit to accept the administration of standardized anti-TB medical drugs including 300 mg/d isoniazid, 450 mg/d rifampicin, 1500 mg/d pyrazinamide, and 750 mg/d ethambutol for 6 months. The symptoms relieved and the patient recovered progressively after that. At present, one year after surgery, the patient is doing well with no adverse effects from surgery and takes part in work and study normally.