TUBERCULOSIS LYMPH NODE PRESENTING AS A CYSTIC MASS OF THE PANCREATIC HEAD

A 31-years-old man, active smoker with no history of tuberculosis, presented an atypical epigastralgia during one month, associated with asthenia and apyrexia. Abdominal examination found epigastric sensitivity. There was no peripheral adenomegalies found. The results of hematological tests were WBC 11900/mm³ and lymphocytes at 3660/mm³, CRP was at 93 mg/l. Liver enzymes were normal except from GGT (2.2N). Abdominal ultrasound found many peripancreatic and hepatic adenopathies and a cystic lesion of the pancreatic head. CT scan found the same and a thickening of the ileum. We suspected a digestive and lymphatic tuberculosis. Tuberculin intradermoreaction test was positive (20 mm) and chest X-ray was negative. Ileocolonoscopy showed superficial small ulcerations of the ileum, pathology examination couldn't confirm tuberculosis origin. CP MRI confirmed the presence of peripancreatic adenopathies and a 5 cm cystic mass adjacent to the pancreatic head with no communication with the main pancreatic duct and homogenous content. Endoscopic ultrasound showed the presence of a polycyclic lesion with heterogeneous liquid content measuring 3 × 5 cm along the hepatic pedicle and coming into contact with the pancreatic isthmus; this lesion was surrounded by multiple adenopathies. The results of fine needle aspiration (FNA) with 22 G needle were the presence of inflammatory material with suppurative necrosis. There were no epitheliod cell granulomas. The detection of Mycobacterium tuberculosis DNA by PCR in the materiel of FNA was positive. The diagnosis of abdominal lymph nodes tuberculosis was established and anti bacillary treatment was started.