case_images: PMC11185014_01
case_images: Arterial phase multi-planar reconstruction of initial abdominal computed tomography scans with pancreatic protocol for Case 1. The full length of the pancreas is demonstrated in these sagittal (leftmost), coronal (middle), and axial oblique (rightmost) images. Shown are the pancreatic head mass (green arrows) seen as an irregular, complex, heterogeneous focus with central non-enhancing components; dilated common bile duct (yellow arrows); and dilated pancreatic duct (cyan arrow). The pancreatic mass visualized here was no longer seen on endoscopic ultrasound done after anti-tuberculosis treatment was started.
case_images: 10.1177_2050313X241262192-fig1.jpg
case_images: PMC11185014_01_10.1177_2050313X241262192-fig1.jpg
case_images: fig1-2050313X241262192
case_images: Abdominal computed tomography (CT) scan with triple contrast enhancement (Figure 1) showed an irregular, complex, heterogeneous focus with central non-enhancing components centered in the pancreatic head, appearing to be hypoenhancing relative to the rest of the pancreatic parenchyma.
case_images: PMC11185014_02
case_images: Initial abdominal computed tomography scan with pancreatic protocol for Case 2. Shown is an ill-defined, iso- to slightly hypoenhancing focus (green arrows) in the region of the pancreatic head and neck. This causes cutoff and upstream dilatation of the common bile duct (yellow arrows) as well as the pancreatic duct (cyan arrows). This focus appears isodense and isoenhancing to the pancreatic parenchyma in the rest of the contrast phases.
case_images: 10.1177_2050313X241262192-fig2.jpg
case_images: PMC11185014_02_10.1177_2050313X241262192-fig2.jpg
case_images: fig2-2050313X241262192
case_images: ALP 253 U/L, AST 29 U/L, ALT 22 U/L, TB 5.24 mg/dL, DB 4.05 mg/dL, Alb 34 g/L, and elevated CA 19-9 at 1147.86 U/mL. Abdominal CT scan with pancreatic protocol showed an ill-defined focus in the pancreatic head and neck region, with consequent pancreatic duct and biliary ectasia (Figure 2).
case_images: Endoscopic ultrasound (EUS) images for Case 2. The left image shows the initial EUS visualizing the pancreatic head mass (green arrow) and common bile duct (orange arrow) as indicated by the labels. The right image shows the EUS after anti-tuberculosis treatment, with the previously seen pancreatic head mass no longer visualized (green arrows). The metal biliary stent (orange arrows) can also be appreciated in the right image, with bile sludge within it.
case_images: 10.1177_2050313X241262192-fig3.jpg
case_images: PMC11185014_02_10.1177_2050313X241262192-fig3.jpg
case_images: fig3-2050313X241262192
case_images: EUS was performed, with findings of a pancreatic head mass that was unresectable based on EUS features (Figure 3). A repeat EUS was done, which no longer showed any pancreatic mass but rather a common bile duct sludge seen as an intraductal hyperechoic focus without posterior shadowing (Figure 3).
case_images: PMC11185014_03
case_images: Imaging studies for Case 3. The pancreatic head mass (green arrow) with resultant common bile duct dilatation (yellow arrow) is shown in the coronal view of the abdominal computed tomography scan image on the left. The right image shows a normal-looking pancreatic head (green arrow) with a characteristic "salt-and-pepper" appearance without any masses visualized on endoscopic ultrasound after anti-tuberculosis treatment. The portal vein is also visualized in the right image.
case_images: 10.1177_2050313X241262192-fig4.jpg
case_images: PMC11185014_03_10.1177_2050313X241262192-fig4.jpg
case_images: fig4-2050313X241262192
case_images: An eventual consult was made in our institution for further management, with an abdominal CT scan (Figure 4) showing an ill-marginated, lobulated, hypoenhancing pancreatic head mass sized 3.5 x 5.4 x 2.6 cm, involving the pancreatic body as well as encasing the common hepatic artery and portal vein. Repeat EUS already showed unremarkable findings without any note of pancreatic masses (Figure 4).