Case Presentation: A 25-year-old man with no past medical history presented with five days of rapidly enlarging neck mass. He recently moved from India to San Antonio and noticed an unintentional weight loss of 20 pounds over the past month with a non-productive cough, nausea and vomiting. Denies neck pain, dysphagia and fever. Physical exam revealed a diffusely enlarged, non-tender anterior 5 cm neck mass without axillary or inguinal lymphadenopathy. The exam was negative for exophthalmos or abdominal tenderness. Laboratory studies showed TSH of 0.009 with free T4 of 1.4 and negative thyroglobulin, TSH receptor, and thyroperoxidase antibodies. Also found to have an elevated alkaline phosphatase to 135. Computed tomography (CT) of the thyroid characterized multilobulated, complex cystic lesions with extension into the right thoracic inlet. CT abdomen revealed a 2.5cm multilobulated complex cystic lesion in the head of the pancreas. Fine needle aspiration of the thyroid and paratracheal lymph nodes revealed +AFB with granulomatous inflammation and necrosis consistent with extrapulmonary tuberculosis (TB). The patient was treated with RIPE therapy and an MRI of the abdomen revealed complete resolution of both the paratracheal swelling and pancreatic mass at three months.

Discussion: Pancreatic TB was first described in 1944, but little data exists regarding the incidence within the United States. Abdominal TB, which encompasses multiple organs and peritonitis, accounts for only about five to twelve percent of new cases per year. In India, a region with much higher overall TB prevalence, the incidence of pancreatic involvement is 8% of all abdominal cases. TB thyroiditis accounts for only 0.6% of all thyroid masses making this a unique presentation of extrapulmonary TB with both pancreas and thyroid involved. There is no universally accepted diagnostic or treatment strategy for pancreatic TB. For management of this patient, we followed an algorithm first suggested by Sharma et al. It utilizes imaging characteristics of the abdominal mass as well as biopsy proven TB in other non-pancreatic sites in order to avoid further unnecessary invasive tests. The use of fine needle aspiration for direct diagnosis of pancreatic TB has yielded variable results of 43-80%. Based on this information and taking into account the patient’s young age as well as possessing no other risk factors, he was spared an invasive and potentially harmful procedure. This diagnosis requires a high index of suspicion but ultimately leads to appropriate treatment and sub-specialty follow up.

Conclusions: Tuberculosis can manifest within a multitude of different organs leading to puzzling symptoms and clinical presentations. By thoroughly investigating each abnormality, clinical context can guide a thorough workup while avoiding unnecessary and invasive procedures but still achieving favorable outcome and appropriate sub-specialty follow up.