The Great Mimicker: Pancreatic Tuberculosis Masquerading as a Pancreatic Neoplasm

Pancreatic tuberculosis is a rare manifestation of extrapulmonary tuberculosis, often mimicking pancreatic cancer clinically and radiologically. We report a 26-year-old immunocompetent farmer from a tuberculosis-endemic area presenting with a two-month history of fever, night sweats, and significant weight loss. Although malignancy was suspected, contrast-enhanced computed tomography of the abdomen showed a complex lesion in the pancreatic body with central necrosis and an enlarged lymph node. Fluorodeoxyglucose positron emission tomography also revealed increased metabolic activity in the lesion. However, endoscopic ultrasound-guided fine-needle aspiration produced caseous necrotic material, and cytology revealed necrotizing granulomas with multinucleated giant cells. Molecular testing identified Mycobacterium tuberculosis, and other supportive findings included an elevated adenosine deaminase level in the cystic fluid and a positive interferon-gamma release assay. The patient was initiated on a standard four-drug anti-tuberculosis regimen and showed rapid clinical improvement within two weeks. Follow-up imaging at six months demonstrated complete resolution of the pancreatic lesion with residual fibrosis, and the patient remained asymptomatic after completing a nine-month treatment course. This case highlights the importance of including pancreatic tuberculosis in the differential diagnosis of pancreatic masses, particularly in endemic areas. A multidisciplinary approach involving endoscopic sampling, histology, and molecular testing is required to differentiate pancreatic tuberculosis from cancer and to ensure timely management.