A Case of Peripancreatic Tuberculous Lymphadenitis Mimicking Pancreatic Malignancy: Diagnosis by Endoscopic Ultrasound-guided Core Biopsy

Pancreatic and peripancreatic Tuberculosis (TB) are uncommon and may closely resemble pancreatic malignancy on imaging. The authors report a 65-year-old immunocompetent male who presented with epigastric pain, weight loss of 5-6 kg, and malaise. Contrast-Enhanced Computed Tomography (CECT) of the abdomen showed a 2.5×1.9×1.7 cm hypoenhancing lesion in the pancreatic head with multiple enlarged peripancreatic lymph nodes showing central necrosis, raising suspicion of pancreatic malignancy. Positron Emission Tomography-Computed Tomography (PET-CT) showed an Fluorodeoxyglucose (FDG)-avid necrotic lesion adjacent to the pancreatic head and neck, along with multiple FDG-avid necrotic peripancreatic lymph nodes and mildly FDG-avid mediastinal and right hilar lymph nodes. Endoscopic Ultrasound (EUS) demonstrated conglomerated peripancreatic lymph nodes measuring approximately 3×1 cm with central calcification. EUS-guided core biopsy showed necrotising granulomatous inflammation, and GeneXpert performed on the tissue was positive for Mycobacterium tuberculosis. The patient was started on anti-tubercular therapy and showed significant clinical improvement, with complete resolution of the lesions on follow-up PET-CT after six months. The present case illustrates the difficulty in distinguishing peripancreatic tuberculosis from pancreatic malignancy based on imaging alone and highlights the importance of EUS-guided tissue acquisition with molecular testing in establishing the diagnosis and guiding appropriate treatment.