Enlarged cervical lymph nodes and elevated liver chemistry tests: a therapeutic dilemma.

We describe the case of a 36-years-old male patient, originating from India, who presented with enlarged cervical lymph nodes and elevated liver chemistry tests. Histologically necrosing granulomas were observed in the lymph nodes, and PCR revealed DNA from mycobacterium tuberculosis. However, in the liver biopsy granulomatous hepatitis without central necrosis was seen. With a positive PCR for mycobacteria from liver tissue and no evidence for other hepatic diseases we started drug treatment with standard quadruple regimen consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide. Five days after onset of therapy, liver chemistry tests rose 10-fold, forcing us to interrupt treatment. Gradual step-wise re-exposition with the same medication after return of liver chemistry tests to baseline was well tolerated without any further side effects. Liver involvement of tuberculosis can have many facets and may be treated by gradual dosing of standard drugs.

[Granulomatous tuberculous hepatitis as cause of fever of unknown origin]. / Hepatitis granulomatosa tuberculosa como causa de fiebre de orígen desconocido

The clinical case of one patient with fever of unknown origin, due to granulomatous hepatitis of tuberculous etiology was presented. The patient was a a 50-year-old woman, with 50 days illness characterized by chills, 39 degrees C fever and heavy diaphoresis. She had a record of seven malaria cases. She looked thin and pale at the initial physical examination. During the evolution, she developed pancytopenia, massive hepatosplenomegaly, jaundice, and anasarca. The patient underwent screening tests for infection, neoplasias, collagenosis, and granulomatous diseases. The laboratory tests showed transaminase-alkaline phosphatase dissociation, which led to the final diagnosis of tuberculosis, through the histological examination of the liver parenchyma. The specific treatment against tuberculosis caused remission of fever, ascites, and hepatomegaly and normalization of liver tests, with satisfactory clinical evolution.

[Pseudotumorous hepatic tuberculosis: laparoscopic appearance]. / Tuberculosis hepática seudotumoral. Aspecto laparoscópico.

Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. Even less common is the finding of a nodular form of local hepatic tuberculosis. There is a growing incidence of the disease related to human immunodeficiency virus. The authors report a case of pseudotumoral hepatic tuberculosis in a patient without AIDS, manifesting as prolonged fever, diagnosed previously as metastatic liver. Imaging studies of the liver and laparoscopic findings suggested metastatic disease. The correct diagnosis was made by histology of biopsies obtained in laparoscopy, which is an easy and cheap method, with less morbidity and mortality than surgical intervention. The case report illustrates the difficulty in reaching the correct diagnosis, most often confused with carcinoma of the liver, primary or metastatic. A greater awareness of this rare clinical entity may prevent needless surgical intervention since the majority of patients respond well to antituberculous chemotherapy.

Tuberculosis hepática: estudio prospectivo clínico-patológico / Hepatic tuberculosis: clinico-pathological prospective study

Los autores realizan un estudio prospectivo para evaluar el compromiso hepático en 19 pacientes con tuberculosis pulmonar activa. El grupo estuvo constituido por 9 personas del sexo masculino y 10 del femenino, con edades que fluctuaron entre los 17 y 33 años. A todos se les efectuó evaluación clínica, bioquimica, radiológica y biopsia hepática percutânea. La sintomatología clínica digestiva fue de poca importancia, el 31.6% se quejó de dolor en hipocondrio derecho y hubo ictericia en un paciente. El compromiso del estado general, fiebre, disminución del peso y anorexia fueron evidentes en el 84.2% de los pacientes, dependientes más del compromiso pulmonar activo. Las transaminasas estuvieron leve o moderadamente elevadas en el 36.8% de las pacientes, la fosfatasa alcalina normal en el 100% y el tiempo de protrombina alterado en 21%. El examen por microscopía de luz demostró: hiperplasia de las células de Kuppfer (100%), regeneración hepatocelular (26.3%), necrosis focal o unicelular (36.8%) e infiltración intralobulillar (36.8%). Granulomas hepáticos se identificaron en sólo dos casos (10.5%). El porcentaje de existencia de hepatitis granulomatosa en TBC pulmonar activa fue bajo (10.5%), comparable con los reportados en otras series creemos que con uso de la laparoscopía y la biopsia hepática dirigida este hallazgo puede incrementarse