A 41-year-old Nepalese male of Aryan origin presented with 3 months history of gradually progressive jaundice, intermittent right upper quadrant pain, and weight loss of 5 kg over a 2-month period. There was no history of cough, fever, hemoptysis or shortness of breath. He had received a BCG vaccine at childhood, but there was no prior history of tuberculosis, or family history of contact.
On examination, patient was deeply icteric with skin scratch marks all over the body. On abdominal examination, he had mild hepatomegaly and a palpable gall bladder. Initial laboratory values revealed a WBC count of 9200/mm3 (90% neutrophils, 10% lymphocytes), haemoglobin 12.7 g/dL, total bilirubin 24.4 mg/dL, conjugated bilirubin18 mg/dL, ALT 96 U/L (normal 5-45 U/L), AST 161 U/L (normal 5-45 U/L), and ALP 593 U/L (normal 42-128 U/L), albumin 3.5 mg/dL and total protein 5.7 mg/dL. His random blood sugar, serum urea and creatinine will within normal limits. A chest X-ray film was normal. Abdominal ultrasound examination revealed an irregular hypoechoic lesion of 3 cm x 4.4 cm in the head and uncinate process of pancreas, and with dilation of entire bile duct system, distended gall bladder with normal pancreatic duct. Contrast enhanced CT scan showed a heterogeneous mass in the pancreatic head and uncinate process of the pancreas. (Figure 1) The gall bladder was distended along with the dilatation of entire biliary tract. Exploratory laparotomy revealed a mass of size 3x2 cm at the head and uncinate process of pancreas with areas of necrosis on cut section, 50 ml of thick pus at the retroduodenal region, dilated distal common bile duct, distended gall bladder and multiple enlarged perichodochal and peripancreatic lymph nodes. The patient underwent pancreatoduodencetomy with intraoperative diagnosis of pancreatic carcinoma. AFB staining of the pus was negative and culture was sterile. However, the histopathology from the pancreatic mass revealed necrotizing granulomatous lesion which was positive for acid fast bacilli. The histopathological picture of the enlarged nodes was of reactive lymphadenitis. (Figure 2) The patient had uneventful postoperative period. After the diagnosis of tuberculosis, antitubercular drugs were started in accordance to DOTS (Directly observed treatment, short-course), and patient is doing well at the follow up after 6 month.