A 5-year-old girl who had no previous medical history was admitted to our hospital with a right groin mass for 2 months and abdominal distension for 15 days. Her symptoms were accompanied by occasional umbilical pain, vomiting, and diarrhea. Physical examination showed acute facial features, malnutrition, abdominal swelling, apparent tenderness, a mass approximately 4 x 3 x 2 cm in size in the right inguinal region, and negative Grey Turner sign and Cullen sign. Routine blood test revealed white blood cells 2.97 x 109/L, neutrophils 47.2%, red blood cells 4.88 x 1012/L, platelets 714 x 109/L, and C-reactive protein 2.06 mg/L. Abdominal enhanced computed tomography (CT) revealed the following findings: (1) the pancreatic duct was significantly dilated, and the surrounding pancreatic head space was unclear; (2) a cystic low-density shadow was observed in the head of the pancreas (Figure 1); (3) massive peritoneal effusion was observed; (4) patchy lymph node enhancement and enlargement were observed in the mesentery; and (5) intestinal aggregation in the upper abdomen along with thickening and enhancement of the bowel wall was observed. Chest CT revealed increased lung markings and no signs of TB.
After admission, the patient presented with diffuse abdominal distension. Laboratory tests indicated pancreatitis (serum lipase 3167 U/L and serum amylase 720 U/L). Serum cancer antigen- (CA-) 125 was increased to 484.5 U/mL (normal is less than 35 U/mL). An abdominal puncture was performed three days after admission. Ascites was red and yellow. Qualitative protein was positive. No acid-fast bacilli were identified via ascites smear. The anti-TB antibody in serum was negative. The purified protein derivative of the tuberculin test and interferon-gamma release assay were negative. No tumor cells were identified in the ascites, and there was no bacterial growth in the ascites for 48 hours. Seven days after admission, the patient underwent laparoscopic exploration. In total, 3600 mL of bloody ascites was present in the peritoneal cavity. Pale and fish-like masses were found. A wide and dark-red flocculent area was visible. Pathological examination revealed an inflammatory exudate. The results of periodic acid-Schiff staining, methenamine silver staining, and acid-fast staining were negative. No bacteria or tubercle bacilli were found in the ascites cultures. Using polymerase chain reaction (PCR), Mycobacterium tuberculosis DNA was identified in the resected abdominal mass. Therefore, the diagnosis of pancreatic TB was made. Fasting, somatostatin, omeprazole, and total parenteral nutrition therapy were administered. Rifampicin (10 mg/kg/day), pyrazinamide (20 mg/kg/day), and isoniazid (10 mg/kg/day) were prescribed. Three weeks later, abdominal pain, abdominal distension, cough, fever, nausea, vomiting, and diarrhea had resolved. The patient was discharged.
Two weeks after discharge, pain around the umbilicus and periumbilical tenderness were reported with nausea and vomiting. Abdominal ultrasonography revealed large pancreatic cysts. The diagnosis of a pancreatic pseudocyst was made, and ultrasound-guided puncture drainage was performed. Giant cystic lesions as thick as the wall and approximately 12 x 9 x 10 cm in size were observed by intraoperative ultrasonography. Approximately 500 mL of brown cyst fluid was expelled. On day 4 after the operation, the patient's general condition was good, and her vital signs were stable. Therefore, she was discharged again. Outpatient antitubercular therapy consisted of isoniazid, rifampicin, and pyrazinamide for 4 months and subsequently isoniazid and rifampicin for 8 months.
At the one-year outpatient follow-up visit, her appetite improved, and she regained the weight she had previously lost. Abdominal CT showed a significant reduction in the cystic low-density shadow of the head and neck of the pancreas (Figure 2). The effect of the antitubercular therapy was significant.