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Introduction

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The HIV/AIDS pandemic has affected the South African population more than most. Tuberculosis (TB) is endemic in South Africa and this has been severely aggravated by the advent of AIDS. 1,2 Tuberculosis presents in many guises, some common, some extremely rare. Often, it is only a high index of suspicion that helps make the diagnosis. We present herein a patient who presented with obstructive jaundice and a mass in the head of the pancreas, which resolved on anti-TB treatment, to serve as a caveat to others.A 33-year-old female was referred to the surgery department of the Pretoria Academic Hospital. She complained of pain in the right hypochondrium, which had been present for two weeks. The pain was constant and not affected by meals. She described her stools as being green in color. The patient weighed 75 kg, which was her approximate expected weight for height. She was jaundiced. None of the typical constitutional symptoms of tuberculosis were reported on questioning, nor was the patient observed to have fever, nausea, vomiting or night sweats during her hospital stay. There was no medical or surgical history of any note. The patient did not have any known TB contacts. The patient had oral candidiasis. There was a 3 cm mass in her left supraclavicular fossa fixed to underlying structures. A vague epigastric mass was felt on clinical examination, which was otherwise unremarkable -the liver appeared to be of normal size and the gallbladder was not clinically palpable. Vital signs were normal throughout her hospital stay.On admission, the patient's full blood count was normal, the liver functions were typical of obstructive jaundice (bilirubin 117.3 mmol/l, ALP 401 IU/l, gGT 462 IU/l, ALT 64 IU/L, AST 57 IU/L), and the CRP was 90 mg/l. Chest X-ray was normal. Due to the endemic nature of tuberculosis in South Africa, a purified protein derivative (PPD) skin test was not performed. Pancreatic enzymes were not tested. Serum albumin was 24 g/l on admission.Abdominal ultrasound showed a large cystic mass in the head of the pancreas. Intra-and extra-hepatic bile ducts were dilated. A computed tomography (CT) scan confirmed the presence of a 4.47 Â 3.37 Â 4.4 cm cystic mass in the head of the pancreas (Figure 1). The mass was thick-walled with septae. There was no sign of intra-abdominal lymphadenopathy. In consultation with the radiologists, a preliminary diagnosis of a periampullary carcinoma was made.