P2285 - From Cancer Concern to Curable Infection: Pancreatic Tuberculosis With Biliary Obstruction Diagnosed via Endoscopic Ultrasound-Guided Fine Needle Biopsy

Award: ACG Presidential Poster Award

Abigail Ellington, MD, Danielle Rambuss, MD, Victoria A. Margolis, MD, Sarah Barbina, MD, Angela G. Niehaus, MD, Jason Conway, MD, MPH, FACG, Girish Mishra, MD, MS, FACG, Darius A. Jahann, MD
Atrium Health Wake Forest Baptist, Winston-Salem, NC

Introduction: Mycobacterium tuberculosis (TB) is an airborne, granulomatous infection that can involve both pulmonary and extrapulmonary sites. Pancreatic involvement is exceedingly rare and often mimics pancreatic malignancy, posing significant diagnostic challenges. We present an exceptional case of pancreatic tuberculosis causing obstructive jaundice, hepatic involvement, and biliary obstruction in an immunocompetent host. Diagnosis was established via endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP), with complete clinical resolution following antitubercular therapy.

Case Description/

Methods: A 30-year-old woman with recent immigration from Mexico presented with abdominal pain and jaundice. Laboratory evaluation revealed a total bilirubin of 3.3 mg/dL, AST 230 U/L, ALT 32 U/L, and alkaline phosphatase 327 U/L. MRI demonstrated a mass in the pancreatic neck, periportal lymphadenopathy, and multiple hepatic lesions, raising concern for metastatic pancreatic cancer (Fig 1A).

The patient underwent EUS with fine needle biopsy (FNB) which identified a 40 mm predominantly cystic mass in the pancreatic neck (Fig 1B) and periportal lymphadenopathy (Fig 1C). Core biopsies of both a periportal lymph node (Fg 1F) and liver lesion (Fig 1E) revealed granulomatous inflammation, without malignant features (Fig 1E). Acid-fast bacilli cultures from these specimens confirmed the diagnosis of TB.

ERCP delineated a high-grade distal biliary stricture with upstream dilation for which plastic stent was placed for decompression (Fig 1D). The patient was started on standard four-drug antitubercular therapy. At six months, there was complete resolution of the pancreas mass, liver lesions, and lymphadenopathy, along with relief of the biliary obstruction.

Discussion: Pancreatic tuberculosis is an uncommon manifestation of TB, even in endemic countries, and is particularly rare in immunocompetent individuals. When present, its location in the pancreas may necessitate EUS-guided tissue acquisition for diagnosis and ERCP for biliary decompression. EUS-FNB offers the advantage of obtaining core tissue with preserved architecture, which is essential for histopathologic evaluation. In the appropriate clinical context, a high index of suspicion is required, as cytopathologic samples must undergo mycobacterium staining and culture to

establish the diagnosis. In this case, early recognition enabled timely initiation of antitubercular therapy, leading to complete clinical and radiographic resolution.


Figure: FIgure 1: (A) MRI of pancreas and liver lesion (B) EUS of 40 mm pancreatic mass (C) EUS of periportal lymph node (D) Cholangiogram of tuberculous biliary stricture (E) Tissue section of liver lesion with granuloma (F) Tissue section of lymph node with granulomatous inflammation

Disclosures:
Abigail Ellington indicated no relevant financial relationships.
Danielle Rambuss indicated no relevant financial relationships.
Victoria Margolis indicated no relevant financial relationships.
Sarah Barbina indicated no relevant financial relationships.
Angela Niehaus indicated no relevant financial relationships.
Jason Conway indicated no relevant financial relationships.
Girish Mishra indicated no relevant financial relationships.
Darius Jahann indicated no relevant financial relationships.

Abigail Ellington, MD, Danielle Rambuss, MD, Victoria A. Margolis, MD, Sarah Barbina, MD, Angela G. Niehaus, MD, Jason Conway, MD, MPH, FACG, Girish Mishra, MD, MS, FACG, Darius A. Jahann, MD. P2285 - From Cancer Concern to Curable Infection: Pancreatic Tuberculosis With Biliary Obstruction Diagnosed via Endoscopic Ultrasound-Guided Fine Needle Biopsy, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.