extrapulmonary tb most commonly affects the intestines , peritoneum , meninges , urogenital system , bone , and lymph nodes ; rarely is it found in the pancreas.1 based on the clinical manifestations and imaging studies , it can be difficult to differentiate pancreatic tb from pancreatic carcinoma . the coexistence of pancreatic carcinoma with pancreatic tb has not been reported previously in the database . this paper presents such a case of pancreatic carcinoma coexisting with pancreatic tb in an adult male patient . a 34-year - old man was admitted to our hospital with a 1-month history of vague epigastric pain . he denied exposure to tb or a personal history of tb . on physical examination , laboratory examination showed : hemoglobin 10.9 g / dl , platelet count 32510/l , white blood cell count 8.6810/l , aspartate aminotransferase 21 iu / l ( normal , iu / l ) , total bilirubin 5.1 mol / l ( normal , 5.0 to 28.0 mol / l ) , direct bilirubin 1.6 mol / l ( normal , < 8.8 mol / l ) , and ca19 - 9 157.80 u / ml ( normal , < 22 u / ml ) . human immunodeficiency virus ( hiv ) serology was negative . abdominal contrast - enhanced spiral computed tomography ( ct ) showed a hypodense mass in the head of the pancreas and a second hypodense mass in the tail of the pancreas . both masses exhibited peripheral enhancement the hepatic artery was encased by the pancreatic head mass and lymph nodes ( fig . 1 ) . based on the available data , an initial diagnosis of pancreatic carcinoma with intrapancreatic metastasis was made . a diagnosis of tb was considered , as it is endemic in china ; however , supportive evidence was lacking . the patient presented with no personal or family history of tb , a normal chest x - ray , and none of the typical symptoms of tb . the operation revealed a firm mass in the head of the pancreas and another mass in the tail of the pancreas , measuring 4.03.83.5 cm and 1.21.01.0 cm , respectively . excisional biopsy of the lymph nodes and fine needle aspiration biopsy ( fnab ) of the pancreatic masses were performed . caseating granulomas with langhans giant cells were found in the specimens from the lymph nodes and the mass in the pancreatic head , consistent with tb ( fig . adenocarcinoma was identified in the biopsy specimens taken from the mass in the pancreatic tail . postoperatively , the histopathology on paraffin section confirmed the diagnosis of pancreatic carcinoma ( fig . 3 ) and tb . however , the acid - fast stain of the caseous material was negative , and the incisional margin , spleen , and a total of 7 lymph nodes were free of tumor . the patient was treated with isoniazid , rifampicin , and ethambutol according to the protocol for standard tb chemotherapy . his family members refused anti - tumor chemotherapy . at the 7-month follow - up , tb is still a common disease in developing countries . with the high prevalence of hiv auerbach3 reported on 1,656 autopsies with tb ; among these cases , 297 ( 17.9% ) had acute generalized tb , but only 14 ( 4.7% ) had pancreatic involvement . paraf et al.4 identified only 11 ( 2.1% ) cases with pancreatic or peripancreatic involvement in 526 miliary tb cases between 1891 and 1961 . the pathogenesis of pancreatic tb has been described : 1 ) lympho - hematogenous spread from an active focus ; 2 ) direct invasion into adjacent celiac and retroperitoneal lymph nodes ; 3 ) toxic allergic reaction of the pancreas in response to generalized tb.5,6 the pancreas is biologically resistant to the infection of mycobacterium tuberculosis . intraparenchymal injection of m. tuberculosis can cause pancreatic lesions , only if abundant inoculum is used . furthermore , an antimycobacterial effect of pancreatic extracts , purified lipases , and deoxyribonucleases has been reported.7 the main clinical manifestations of pancreatic tb include epigastric pain ( 64% ) , fever ( 53% ) , weight loss ( 40% ) , and anorexia ( 36%).8 contrast - enhanced ct may demonstrate hypodense and/or multiloculated masses , diffuse enlargement of the pancreas , and stenosis of the pancreatic duct . these features are nonspecific and can resemble pancreatic carcinoma , pancreatitis , and lymphoma.9 the diagnosis of pancreatic tb should be considered when the following are observed : 1 ) young patients with a personal history of tb or exposure to tb ; 2 ) patients with active tb ; 3 ) congenital or acquired immune deficiency ; 4 ) positive tuberculin test , elevated erythrocyte sedimentation rate , or abnormal serum globulin ; 5 ) ultrasound and/or ct demonstration of focal hypoechoic or hypodense masses with ring enhancement or internal separation . when pancreatic tb is suspected , ultrasound or ct - guided fnab may help determine the diagnosis . even if the initial microbiological results are negative , conventional techniques and polymerase chain reaction should be performed to avoid unnecessary laparotomy.10 once the diagnosis of pancreatic tb is confirmed , standard chemotherapy has been shown to have good curative effect.11 our hospital did not have the needle systems for fnab ; consequently , ultrasound and/or ct - guided fnab was not undertaken preoperatively . gouya et al.12 reported only 2 patients out of a group of 30 patients with insulinomas had more than one insulinoma . in 1998 , klein et al.13 retrospectively analyzed 66 patients with metastases to the pancreas and identified multiple tumors in 11 patients . in our case , the definitive diagnosis was made by an intraoperative fnab . the sensitivity , specificity , false - positive rate , and complication rate for intraoperative fnab were 93% , 100% , 0% , and 0% , respectively.14 the biopsy method can be an important tool utilized to avoid unnecessary resection , and to reduce the morbidity and mortality that accompany inappropriate surgical interventions . in conclusion , pancreatic tb should be considered in the differential diagnosis of pancreatic masses , especially in areas where tb is prevalent . to avoid unnecessary laparotomy or resection , histopathological and microbiological evaluations if multiple masses are present , biopsies must be taken from all the masses in order to direct subsequent therapy .
pancreatic tuberculosis ( tb ) is extremely rare and mimics pancreatic carcinoma both clinically and radiologically . 
 this paper discusses the occurrence of 2 heterogeneous masses located in the head and tail of the pancreas in an adult male . in this patient , 
 laparotomy was performed because of the high suspicion of pancreatic carcinoma . 
 intraoperative fine needle aspiration biopsy revealed the coexistence of pancreatic carcinoma with pancreatic tb , and a combined resection of the distal pancreas and spleen was successfully performed . 
 following surgery , the patient received standard chemotherapy for tb . at 7-month follow - up , computed tomography showed resolution of the mass in the pancreatic head . 
 clinicians must maintain a high index of suspicion for pancreatic tb in patients with pancreatic masses . 
 the coexistence of malignancy and tb should be considered when patients present with multiple pancreatic masses .