PMC5610859_01
Electronic gastroscope and endoscopic ultrasonography both showed the abnormality of the duodenal mucosa. (a) Electronic gastroscope revealed that there was a mucosal protrusion at the first portion of the duodenum (duodenal bulb) with an ulcerated surface (marked with a circle). (b) NBI and ME showed that the local vascular was disordered, and gland duct disappeared. (c) EUS showed that the hypoechoic mass with uniform echo was at duodenal bulb.
CRIM2017-4396759.001.jpg
PMC5610859_01_CRIM2017-4396759.001.jpg
fig1
The lesion was closely adjacent to the serosa (Figure 1).
The CT scan revealed that the enlargement of the head of pancreas had an irregular density and unclear boundary. Moreover, inhomogeneous enhancement and progressive enhancement appeared after using iodinated contrast material. (a) CT scan, (b) arterial phase, (c) portal phase, and (d) delayed phase image.
CRIM2017-4396759.002.jpg
PMC5610859_01_CRIM2017-4396759.002.jpg
fig2
CT images also revealed that the arteria hepatica was enveloped which mimicked a pancreatic head carcinoma (Figure 2).
The MRI graph revealed that the head of the pancreas increased with abnormal signal, T2W1 showed a mixed signal, mainly with high signal, T1W1 showed a low signal, positive and negative phase showed no lipid component within the lesion, and DWI showed a high signal which was delayed enhancement unevenly. In addition, there were a slight dilatation of common bile duct and no dilatation of pancreatic duct. T2W1 graph (a), positive and negative phase diagrams (b-c), LAVA prescanned graph (d), LAVA graphs (e-h), delayed enhancement graph (i), and DWI graph (j).
CRIM2017-4396759.003.jpg
PMC5610859_01_CRIM2017-4396759.003.jpg
fig3
The contrast enhanced MRI had heterogeneous density, with the vascular involvement; therefore, the neoplastic changes should be strongly considered (Figure 3).
The histopathological pictures. (a) Whipple surgical specimens contained the pancreas, duodenum, partial stomach, and the omentum. The lesion was located on the pancreatic head. ((b) and (c)) HE staining. Granulomatous nodules consisting of lymphocytes, epithelioid cells, and multinucleated giant cells can be seen at the site of the lesion. Necrosis can be seen in the middle of nodules which were marked with an asterisk. The triangle marked the lymphocytes around the nodules. The arrow indicated the multinucleated giant cells reaction. These pathological features suggested tuberculous lesions.
CRIM2017-4396759.004.jpg
PMC5610859_01_CRIM2017-4396759.004.jpg
fig4
Tubercular nodules were seen in the lymph nodes of intestinal adipose tissues. (4) Individual caseating granulomatous inflammation and necrosis were found in the omentum of lesser curvature of stomach. (5) Many lymph nodes isolated from operation displayed the pathological characteristics of tuberculosis (Figure 4). The patient was thereafter advised to transfer to the Intensive Care Unit to accept the administration of standardized anti-TB medical drugs including 300 mg/d isoniazid, 450 mg/d rifampicin, 1500 mg/d pyrazinamide, and 750 mg/d ethambutol for 6 months. The symptoms relieved and the patient recovered progressively after that.