Isolated Pancreatic Tuberculosis in an Immunocompetent Host: A Diagnostic Challenge

Pancreatic tuberculosis (TB) is rare and may closely mimic pancreatic malignancy, most often in immunocompromised patients. We describe the case of a man in his early 30s who presented with progressive epigastric pain, anorexia, fatigue, and 14 kg of weight loss. Computed tomography (CT) demonstrated a multicystic lesion in the pancreatic head encasing the coeliac axis with necrotic lymphadenopathy, appearances highly suspicious for malignancy. The case was reviewed at a regional multidisciplinary tumour meeting, and surgical resection was considered. Endoscopic ultrasound with fine needle biopsy initially demonstrated necrotising granulomatous inflammation; however, Ziehl-Neelsen staining was negative, and mycobacterial cultures were not requested. Six weeks later, a repeat biopsy demonstrated a culture positive for Mycobacterium tuberculosis. The patient was treated with a six-month course of anti-tuberculous therapy, with complete clinical and radiological recovery. This case highlights the importance of considering pancreatic TB even in immunocompetent patients and emphasises that mycobacterial cultures should be requested whenever granulomas are identified. Early repeat sampling can prevent misdiagnosis, unnecessary surgery, and delays in curative treatment.