The Great Mimicker: Pancreatic Tuberculosis Masquerading as a Pancreatic Neoplasm

Pancreatic tuberculosis is a rare manifestation of extrapulmonary tuberculosis, often mimicking pancreatic cancer clinically and radiologically. We report a 26-year-old immunocompetent farmer from a tuberculosis-endemic area presenting with a two-month history of fever, night sweats, and significant weight loss. Although malignancy was suspected, contrast-enhanced computed tomography of the abdomen showed a complex lesion in the pancreatic body with central necrosis and an enlarged lymph node. Fluorodeoxyglucose positron emission tomography also revealed increased metabolic activity in the lesion. However, endoscopic ultrasound-guided fine-needle aspiration produced caseous necrotic material, and cytology revealed necrotizing granulomas with multinucleated giant cells. Molecular testing identified <i>Mycobacterium tuberculosis</i>, and other supportive findings included an elevated adenosine deaminase level in the cystic fluid and a positive interferon-gamma release assay. The patient was initiated on a standard four-drug anti-tuberculosis regimen and showed rapid clinical improvement within two weeks. Follow-up imaging at six months demonstrated complete resolution of the pancreatic lesion with residual fibrosis, and the patient remained asymptomatic after completing a nine-month treatment course. This case highlights the importance of including pancreatic tuberculosis in the differential diagnosis of pancreatic masses, particularly in endemic areas. A multidisciplinary approach involving endoscopic sampling, histology, and molecular testing is required to differentiate pancreatic tuberculosis from cancer and to ensure timely management.