A 41-year-old Thai female presented to her primary physician with a history of right upper quadrant pain. While the pain had been present for several years, it had worsened considerably over the past year, prompting her to seek medical attention. The patient denied weight loss, but did complain of low-grade fevers and chills. Her past medical history was unremarkable. The patient was born in Thailand and had migrated to the United States 6 years ago.
On physical examination, she was noted to be afebrile and his other vital signs were normal. There were no significant findings on examination of his lungs, heart, or abdomen.
Her laboratory studies results were as follows: white blood cell count 7.4/mm (reference range: 3.8-10.8/mm), hemoglobin 11.8 g/dL (reference range: 13.2-17.1 g/dL). Her white blood cell differential count was normal. Her sedimentation rate was elevated at 45 mm/h (reference range: 0-20 mm/h). Other studies including serum chemistries, liver function tests, and blood cultures were non-revealing. Gastrointestinal tumor markers carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) were both within normal limits. Her chest radiograph was normal. On abdominal computed tomography (CT) scan demonstrated a 5.1 cm x 2.8 cm multi-loculated solid lesion in the head of the pancreas concerning for a primary malignancy along with several enlarged lymph nodes in the peripancreatic region.
An endoscopic ultrasound (EUS) was performed which revealed a 4.3 cm x 2.5 cm hypoechoic, homogenous mass lesion with a cystic component within the pancreatic head (Fig. 1). In addition, an oval, 1.1 cm x 1.2 cm heterogeneous lymph node adjacent to mass was seen (Fig. 2). EUS- guided fine needle aspiration (EUS-FNA) of the lesion was performed with 25-G needle. Cytology from the mass revealed necrotizing granulomatous inflammation with no evidence of malignancy. The acid-fast bacilli (AFB) stain was negative. Subsequently, the AFB culture was found to be positive for Mycobacterium tuberculosis complex from the pancreatic mass cell block and found to susceptible to ethambutol, isoniazid, pyrazinamide and rifampin. She was treated with these 4 drugs for 2 months followed then rifampin and isoniazid for a further 7 months. At the end of therapy, her abdominal pain and fever had resolved and she maintained a normal appetite and weight.