Peripancreatic Tuberculosis Mimicking Metastatic Pancreatic Malignancy With Hepatic Lesions

A 61-year-old woman presented with chronic constipation, epigastric pain, intermittent fever, night sweats, anorexia, and marked weight loss. Imaging showed porta hepatis and peripancreatic lymphadenopathy, small hepatic lesions, and a pancreatic-region lesion, raising concern for metastatic pancreatic malignancy or lymphoma. The initial liver biopsy was negative for metastatic carcinoma and lymphoma. Surgery was considered but canceled after magnetic resonance cholangiopancreatography did not confirm a definite pancreatic mass requiring operative management. A repeat core biopsy of the presumed pancreatic-region lesion sampled lymph node tissue and showed caseating granulomatous inflammation with positive acid-fast staining. PCR testing later confirmed Mycobacterium tuberculosis complex DNA. Four-drug antituberculous therapy was started before PCR confirmation because the pathology and acid-fast staining strongly supported tuberculosis. The patient improved clinically and biochemically after treatment. This case supports that repeat targeted tissue sampling should be pursued when malignancy-like pancreatic-region findings are discordant with pathology, particularly in tuberculosis-endemic settings.