Two cases of pancreatic tuberculosis in immunocompetent individuals presenting as diabetes mellitus: An overview of clinical features, diagnosis and management

Mycobacterium tuberculosis (TB) disease is a major global health problem affecting 10.6 million people worldwide, and India alone contributes 28% to this burden. Pancreatic TB is considered an extremely rare entity which closely mimics pancreatic carcinoma. However, while 87% of the total globally notified TB cases are from 30 high-burden countries mostly from Asia, about 45% of pancreatic TB cases are from developed countries. This suggests that the identified cases of pancreatic TB in developing counties are just the tip of iceberg, and many cases either remain undetected or wrongly diagnosed. The majority of the patients with pancreatic TB undergo extensive evaluation and frequently undergo major abdominal surgeries since pancreatic carcinoma is often considered as the most probable diagnosis before TB. Here, 2 cases of pancreatic TB managed separately at two different centers are described. Both cases presented with significant unintentional weight loss and poor glycemic control which is an unusual presentation for pancreatic TB. Imaging showed pancreatic mass lesions, and initially pancreatic carcinoma was considered by the treating physicians. Chromogranin A in both patients and tumor markers done in one of the patients were negative. Both the patients underwent Ga-68 DOTANOC PET/CT scan, and one of the patients even showed multiple DOTANOC avid lesions. Owing to contradictory biochemical and imaging findings, biopsy of the pancreatic mass was done which clinched the diagnosis of pancreatic TB. On starting standard anti-tubercular therapy (ATT), both patients showed clinical and radiological recovery with a significant regain of glycemic control. The clinical features, appropriate investigation including imaging and tissue biopsy, and treatment options are described in the article for better understanding of the disease. This may guide clinicians in early detection of pancreatic TB with least invasive diagnostic procedures.