Hepatic TB

Case Report

BY Dr Samy Zaky / Dr Nabiele El-Nohmany MDTropical Medicine Al-Azhar University

Case Report
A 26-year-old engineering presented with 5 month history of upper abdominal pain, dyspepsia,& weight loss. Clinical examination: fever, epigastric & right upper quadrant tenderness, with a smooth tender 4 cm hepatomegaly. Initial blood results revealed: - a microcytic anemia (Hb 10.3 g/dL, MCV 73.4 fl), -raised inflammatory markers (ESR 126, CRP 178 mg/L), -an elevated alkaline phosphatase (153 IU/L).

Abdominal ultrasound: a 6.5-cm heterogenous mass in the left lobe of the liver suggestive of HCC.
Contrast enhanced abdominal CT scan -6 x 5 cm mixed attenuating lesion in the left lobe, -4cm lesion in the right lobe of the The appearances: liver. suggestive of either lymphoma or HCC.

Serum tumour markers

AFP, CEA, CA 19-9: were normal

II- Diagnosis
HFL by US &|or AFP > 200

M. Triphasic Helical CT

Conclusive*

Not conclusive Tumor size

>2 cm AFP>200 AFP< 200

< 2 cm

Liver biopsy

* Hypervascularity :in arterial phase & washout in the early or delayed

venous phase)

Samy zaky

a guided liver biopsy:

Histology revealed granulomatous inflammation associated with Langhans giant cells suggesting mycobacterial infection.

a granulomatous inflammation, little preservation of liver architecture, and presence of Langhans cells (arrow). (200 magnification, H and E stain)

Aspiration of 100 mL of thick purulent material was performed under ultrasound guidance. Although Ziehl-Nielsen stain failed to demonstrate acid-fast bacilli, culture demonstrated the presence of Mycobacterium tuberculosis, sensitive to quadruple therapy. Plain chest radiology & thoracic CT: no evidence of pulmonary TB. HIV serology was negative.

 The patient was commenced on ethambutol, isoniazid, pyrazinamide, and rifampicin. Within 3 months of therapy, the patient was asymptomatic with normal serum inflammatory markers.

Repeat CT scan following 6 months of antituberculous therapy revealed

a complete resolution of the lesions.

Hepatic TB
Hepatic involvement can be seen in up to 80% of disseminated cases of TB. Isolated tuberculous involvement of the liver is considered rare (low O2 tension within the liver) Primary hepatic TB in absence of immunocompromise is extremely rare.

Hepatic TB
Hepatic TB has been classified by Levine into: (a) Miliary TB; (b) pulmonary TB with hepatic involvement; (c) primary liver TB; (d) focal tuberculoma or abscess; or (e) tuberculous cholangitis.

 Tuberculous cholangitis may present with jaundice & fever. Focal liver abscess: right upper quadrant abdominal pain, fever, night sweats, anorexia, and weight loss.
The most frequent examination findings include abdominal tenderness with or without a palpable mass & occasional jaundice.

Laboratory investigations often reveal an elevated alkaline phosphatase normal ALT and AST. Less specific findings include anemia, hypoalbuminemia, and hyponatremia.

Imaging studies can pose a diagnostic challenge, with many DD, including primary HCC. US: Hypoechoic nodules are usually seen. CT findings: usually reveal a round hypodense lesion with slight peripheral enhancement and, occasionally, areas of focal calcification.

Noninvasive diagnosis is therefore difficult, and up to 90% of cases require a laparotomy to make the diagnosis. primary hepatic tuberculoma (rare) should be considered among the DD of space-occupying lesions of the liver .

 The histologic findings often achieve the diagnosis, with features of caseating granulomatous necrosis. Langhans-type giant cells are often present with a mixed inflammatory infiltrate including plasma cells, eosinophils, & lymphohistiocytic cells.

 Low sensitivity of both acid-fast staining (0-45%) and culture (10-60%) mean diagnosis can still be difficult.
However, the use of PCR to directly detect Mycobacterium tuberculosis and other recent investigations are increasing and may improve sensitivity rates.

Treatment of hepatic TB
quadruple therapy for 1 year, and signs of clinical improvement within 2-3 months appear. The use of percutaneous drainage has also been advocated. Mustard and colleagues suggested features associated with successful drainage included: (1) unilocular abscess; (2) safe access route for instillation of drainage catheter; and (3) a sterile uncontaminated compartment.