Misdiagnosed as pancreatic cancer seven years ago, a 29-year-old woman suffered from left-sided portal hypertension caused by peripancreatic lymph node tuberculosis: a case report and literature review

Background: As the only curable portal hypertension, left-sided portal hypertension (LSPH) is a very rare clinical syndrome. With normal liver function, LSPH is mostly due to pancreatic disease and its complications that cause spleen vein compression, inflammatory wall thickening or lumen blockage, isolated splenic vein thrombosis, restricted splenic vein reflux, finally resulting in increased splenic vein pressure, opened collateral circulation, and bleeding from isolated gastric varices. With a quiet occurrence, LSPH often lacks specific symptoms, which finally leads to difficult diagnosis. Therefore, acuminous options of clinical examination are exceedingly crucial. Splenectomy is the prime treatment for cases complicated by variceal bleeding, but the effect of treatment depends mainly on the condition of the primary disease. Other than these, diseases resulting in LSPH often need to be distinguished from pancreatic cancer, so it is necessary for us to pay more attention to the diagnosis and treatment of LSPH. Case presentation: Here, we report a case of 29-year-old women who was admitted to the hospital for repeated hematemesis and black stool, with a differential diagnosis of pancreatic cancer seven years ago. Abdominal computed tomography (CT), CT angiography (CTA), portal phase three-dimensional vascular reconstruction, and gastroscopy indicated varicose gastric fundus veins, pancreatic mass, and enlarged peripancreatic lymph nodes. Erythrocyte, platelet, and leukocyte counts in decline, positive gamma interferon release assay, and normal liver function were given by laboratory examination. Abdominal exploration, splenectomy, varicose veins dissection, and lesions resection were performed by laparotomy. After surgery, the diagnosis of lymph node tuberculosis was confirmed by the technology of biopsy. Based on mention above, a diagnosis of LSPH caused by peripancreatic lymph node tuberculosis was confirmed. Postoperative evolution was steady, and the patient was in ideal clinical status


Abstract
Background: As the only curable portal hypertension, left-sided portal hypertension (LSPH) is a very rare clinical syndrome. With normal liver function, LSPH is mostly due to pancreatic disease and its complications that cause spleen vein compression, inflammatory wall thickening or lumen blockage, isolated splenic vein thrombosis, restricted splenic vein reflux, finally resulting in increased splenic vein pressure, opened collateral circulation, and bleeding from isolated gastric varices. With a quiet occurrence, LSPH often lacks specific symptoms, which finally leads to difficult diagnosis. Therefore, acuminous options of clinical examination are exceedingly crucial. Splenectomy is the prime treatment for cases complicated by variceal bleeding, but the effect of treatment depends mainly on the condition of the primary disease. Other than these, diseases resulting in LSPH often need to be distinguished from pancreatic cancer, so it is necessary for us to pay more attention to the diagnosis and treatment of LSPH.
Case presentation: Here, we report a case of 29-year-old women who was admitted to the hospital for repeated hematemesis and black stool, with a differential diagnosis of pancreatic cancer seven years ago. Abdominal computed tomography (CT), CT angiography (CTA), portal phase three-dimensional vascular reconstruction, and gastroscopy indicated varicose gastric fundus veins, pancreatic mass, and enlarged peripancreatic lymph nodes. Erythrocyte, platelet, and leukocyte counts in decline, positive gamma interferon release assay, and normal liver function were given by laboratory examination. Abdominal exploration, splenectomy, varicose veins dissection, and lesions resection were performed by laparotomy. After surgery, the diagnosis of lymph node tuberculosis was confirmed by the technology of biopsy. Based on mention above, a diagnosis of LSPH caused by peripancreatic lymph node tuberculosis was confirmed. Postoperative evolution was steady, and the patient was in ideal clinical status at 3 months follow-up.

Case Presentation
The women underwent debridement and drainage for cervical lymph node tuberculosis nine years ago. Seven years ago, because of abdominal pain, the patient was examined by abdominal computed tomography (CT) in other hospital, which reported that there was a mass in pancreas body with enlarged lymph nodes in abdominal cavity. Naturally, the 29year-old women was suspected as pancreatic cancer with lymphatic metastasis. However, except CT report, the specific clinical examination index of the patient in other hospital was unavailable. Two years after symptoms relief by treatment of Chinese traditional medicine, the patient showed repeated vomiting and melena for 5 years. In our hospital, the patient stated that her mental, appetite and sleep was normal, with ochrodermia, but without fever, jaundice, petechiae, and ecchymoses. Physical examination showed a good general condition without abdominal tenderness, abdominal muscle tension, rebound pain, abdominal mass, and hepatomegaly. Additionally, there were no swelling in patient's cervical, supraclavicular, axillary and inguinal lymph nodes.
To clarify the cause, the blood biochemical and blood routine examination were performed. The blood biochemical results reported adenosine deaminase (ADA) and liver function within a normal range, the detailed blood biochemical results were shown in Table 1. The blood routine examination indicated erythrocyte, platelet, and leukocyte counts in decline, other blood routine results were reported in Table 2. In addition, the alpha fetal protein (AFP), tumor associated antigen 125 (CA125), and tumor associated antigen 199 (CA199) were normal. Tests for infection with human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and mycobacterium tuberculosis were negative, but gamma interferon release assay was positive.
In order to further diagnose, imaging examinations were performed by us, which including abdominal non-contrast and contrast-enhanced CT, CT angiography (CTA), CT venography (CTV), and portal phase three-dimensional vascular reconstruction. Non-contrast and contrast-enhanced CT indicated that not obviously enhanced in both arterial and venous phases, a heterogeneous, no vascular, and low-density mass is located in pancreas body, with poorly defined edges and a 3.1 × 2.0 cm diameter ( Figure 1A). An intumescent spleen and multiple nodular dense shadows around pancreas, hepatic hilar region, and mesenteric were also detected by CT ( Figure 1A). On CTA, CTV, and portal phase threedimensional vascular reconstruction graphy, enlarged splenic vein, narrowed start section of the splenic vein, and tortuous gastric veins were observed ( Figure B and Figure D). Meanwhile, we operated lesion excision for biopsy. In operating field an enlarged spleen with a 34 × 25 × 15 cm diameter was observed. After dissociating peritoneal adipose tissue, we caught up with that the left gastric vein, right gastric vein, left gastroepiploic vein, and right gastroepiploic vein are extensively tortuous and dilated ( Figure 2A). As the deepening dissection, we could see swelling lymph nodes at greater curvature, hepatoduodenal ligament, and lower margin of pancreas ( Figure 2B). We considered the mass occupying the lower margin of the pancreas to be an abscess by intraoperative ultrasound. Expressing a caseous necrosis profile, the sample was submitted to biopsy, and a necrotizing granulomatous lymphadenitis compatible with tuberculosis was observed ( Figure 2C and 2D). After these results, a microbiological study was also performed, obtaining a suspiciously positive Ziehl-Neelsen staining. Therefore, the diagnosis of left-sided portal hypertension caused by lymph node tuberculosis was confirmed. According to the current clinical evidences, we inferred that the diagnosis of patient seven years ago should be peripancreatic lymph node tuberculosis rather than pancreatic cancer.

Discussion And Conclusions
Tuberculosis is a common pathology in undeveloped countries. However, due to increasing immigration and cases of HIV immunosuppression, its presence is increasing in developed countries in recent years [23]. Pulmonary tuberculosis is the most frequent form of presentation, but celiac lymph node forms are uncommon [24][25][26]. In this article, we reported a female patient who suffered from left-sided portal hypertension resulting from peripancreatic lymph node tuberculosis, misdiagnosed as pancreatic cancer seven years ago in other hospital. Lacking specific symptoms, the patients with peripancreatic lymph node tuberculosis mainly express abdominal pain, constitutional syndrome, jaundice, emaciation, and pancreatitis or abdominal mass, which are similar to pancreatic cancer. . In term of treatment, asymptomatic patients whether need treatment remains controversial, but it is necessary to interevent for patients with active bleeding. Besides improving bleeding, it is often necessary to treat the primary disease [16,17,19,43,44]. According to patient's clinical condition, there are several methods to relieve isolated gastric bleeding. Enjoying ability of reducing venous blood reflux, splenectomy remains the preferred treatment for patients with gastric bleeding due to left portal hypertension, and splenic artery embolization can be used as a supplement for patients who are not suitable for splenectomy [13,16,17,19,[43][44][45]. Endoscopic therapy has great advantages in the treatment of acute massive gastric bleeding, but the rebleeding is unavoidable [46][47][48][49]. We are also considering whether left portal hypertension due to mechanical compression can be corrected by stent implantation, which will be our future research direction. In our therapeutic procedure, splenectomy and varicose veins dissection were performed to intervene hypersplenism and severe varices. In summary, the treatment of patients with left portal hypertension should be tailored to maximize the benefit of patients.
In conclusion, we state a very interesting case. Experiencing a misdiagnosis, a 29-year-old woman suffered from LSPH resulting from peripancreatic lymph node tuberculosis. LSPH is a very rare clinical syndrome, and we reported the first case of LSHP caused by peripancreatic lymph node tuberculosis. For us, it is of necessity to introduce this case to provide reference for clinical diagnosis and treatment of LSPH. Availability of data and materials: Not applicable.

List Of Abbreviations
Competing interests: The authors declare that they have no competing interests.
Funding: Not applicable.
Authors' contributions: DY and JH wrote the manuscript. JG and JL conceived the report. XL and FX accumulated the clinical materials. All authors contributed to the critical revision of the report for important intellectual content. All authors read and approved the final manuscript. Tables   Table 1.