We report the case of a 29-year-old male from the Indian subcontinent (a tuberculosis (TB)-endemic region) residing in Qatar, who presented with a three-day history of epigastric pain, dark urine, and pale stools. He had no known TB exposure, was HIV-negative, and had received the Bacillus Calmette-Guérin or BCG vaccination in childhood. Physical examination revealed scleral icterus without peripheral lymphadenopathy. Initial imaging showed a dilated common bile duct (CBD) (10 mm) and an overdistended gallbladder with sludge. Magnetic resonance imaging demonstrated conglomerated necrotic lymphadenopathy in the portacaval and precaval regions (the largest measuring 44 × 25 mm), causing smooth extrinsic compression of the distal CBD. Contrast-enhanced CT confirmed central necrosis with peripheral rim enhancement, favoring a tuberculous etiology over a malignant one. Endoscopic ultrasound-guided fine needle biopsy of the peripancreatic lymph nodes revealed necrotizing granulomatous inflammation with caseous necrosis. Ziehl-Neelsen staining for acid-fast bacilli was negative, which can occur in paucibacillary TB. Xpert MTB/RIF Ultra assay detected Mycobacterium tuberculosis complex DNA without rifampicin resistance mutations. Mycobacterial culture was sent and remains pending. The patient was HIV-negative, and QuantiFERON-TB Gold Plus was positive. After consultation with the infectious diseases team, he started a hepatoprotective anti-tubercular regimen (moxifloxacin, ethambutol, amikacin, and linezolid with pyridoxine) due to significant baseline hepatocellular injury (alanine aminotransferase peaking at 465 U/L), resulting in significant clinical and biochemical improvement. At three- and six-month follow-up, liver function tests normalized, and repeat imaging showed near-complete resolution of lymphadenopathy with no residual biliary dilatation. He was discharged on therapy with close outpatient follow-up. This case highlights the importance of considering tuberculous peripancreatic lymphadenitis in the differential diagnosis of obstructive jaundice, particularly in young patients from TB-endemic regions, and underscores the critical role of tissue acquisition for definitive diagnosis.
Hariri et al. (Mon,) studied this question.