Hepatic tuberculosis masquerading as malignancy.

BACKGROUND AND AIMS: Hepatic tuberculosis (HTB) is rare and mimics neoplastic liver lesions clinico-radiologically leading to misdiagnosis and even unnecessary surgery. METHODS AND MATERIAL: We analysed 43 cases of HTB diagnosed at a referral cancer centre over 10 years. Clinical details, investigations and treatment received were noted. RESULTS: The median age was 46 years with a female preponderance (58%). HTB was diagnosed incidentally in 28% cases during surveillance imaging for a previous cancer. Constitutional symptoms (31, 72%), abdominal pain (25, 58%), fever (12, 28%), hepatomegaly (22, 51%), elevated alkaline phosphatase (34, 79%), elevated aminotransferases (18, 42%) and hypoalbuminemia (19, 45%) were common features. All cases had negative HIV serology and normal tumor markers. Twenty-two (52.5%) had solitary liver lesion and lesions > 2 cm in 28 (65%). Ultrasound showed hypoechoic lesions in 31 of 33 cases. Computed tomography showed hypodense lesions (43,100%) with mild peripheral enhancement (32, 74%). Calcifications (5, 12%) and capsular retraction (8, 19%) was uncommon. MRI was performed in seven cases commonly showed T1 hypointense, T2 hyperintense lesions with restricted diffusion. Histopathology showed granulomatous inflammation (42, 97.5%), Langhan's giant cells (41, 95%) and caseation necrosis (35, 85%). Acid-fast stain and PCR positivity was uncommon. Extrahepatic organs were involved in 20 (46.5%). HTB mimicked cholangiocarcinoma (25, 58%), liver metastasis (11, 26%) and lymphoma (3, 7%). Six patients underwent liver resection with a presumptive diagnosis of cancer without a preoperative biopsy. All patients received antitubercular therapy, 37 had clinico-radiological response, there were 3 deaths and 3 patients were lost to follow-up. CONCLUSION: HTB is rare and can mimic a malignancy clinico-radiologically. Calcifications and pseudocapsule appearance on multiphase CT scan may help in differentiating HTB from hepatic malignancy. Tumor markers are normal while histopathology is generally diagnostic. A high index of suspicion is required to avoid unnecessary surgery as the patients respond well to ATT. TRIAL REGISTRATION: This is a retrospective and observational study hence clinical trial registration is not applicable.

Diagnostic imaging of hepatic tuberculosis: case series.

BACKGROUND: Hepatic tuberculosis (TB) shows non-specific symptoms, and liver imaging may provide diagnostic clues. Here we describe a series of patients with hepatic TB showing characteristic radiological findings. METHODS: Single-centre retrospective evaluation of patients with hepatic TB diagnosed over a period of 16 years who underwent ultrasound, computed tomography (CT) and/or magnetic resonance imaging (MRI). Hepatic lesions were classified as miliary, nodular, serohepatic or cholangitis. RESULTS: Of 14 patients with hepatic TB, five were co-infected with the human immunodeficiency virus. All patients had additional extrahepatic TB localisations. An interferon-gamma release assay was performed in 11/14 patients, ultrasound and CT were available for all patients and MRI for four. Observed patterns were miliary (n = 6) with multiple nodules < 2 cm; nodular (n = 5), characterised by a variable number of nodules (2-7 cm); and serohepatic (n = 3), with multiple nodular subcapsular lesions with a thin, smooth wall. Shared findings were hypoechoic lesions on ultrasound, hypodense lesions with ring enhancement on CT, while MRI lesions were hypointense on T1- and hyperintense on T2-weighted images. CONCLUSIONS: Ultrasound, CT and MRI can independently contribute to detection of hepatic TB. While a miliary pattern or calcifications are characteristic, no pattern is completely pathognomonic and the diagnosis depends on microbiological evidence. Particularly in risk groups, characteristic radiological findings may prompt targeted diagnostic work-up.

What remains to surgeons in the management of abdominal tuberculosis? A 10 years experience in an endemic area.

BACKGROUND: Tuberculosis (TB) is a common endemic disease in Tunisia. Abdominal location is rare. Early diagnosis of abdominal TB remains difficult due to its non-specific clinical presentations. The aim of our study is to highlight the characteristics of the different presentations, to characterize tools contributing to a positive preoperative diagnosis, and finally to assess the role of surgery in the management of this entity. MATERIALS AND METHODS: A retrospective review from 2005 to 2015 identified 90 cases of confirmed abdominal TB managed in the Department of General Surgery of the Habib Thameur Hospital. The diagnosis was established by histopathology examination for all cases. This study was approved by the ethical committee. RESULTS: The mean age of the patient was 44.13 years with a sex ratio (M/F) of 0.34. We collected 56 cases of peritoneal TB, 12 cases of abdominal lymph node TB, 10 cases of intestinal TB, four cases of hepatic TB, and two cases of gallbladder's TB. For six patients, an association of many localizations was noted. The diagnosis was suspected on clinical, biological, and morphological arguments, but the confirmation was always made by surgical exploration and pathological examination of removed specimens. Surgical management was urgent in complicated cases (13.3%). Laparoscopy was performed in 71 cases (78.9%). Laparoscopic features of peritoneal TB were specific and always confirmed by histological examination. CONCLUSION: Despite the wide range of examination available for the preoperative exploration of abdominal TB, diagnosis is usually late and difficult. TB is a medical condition. However, surgical exploration is frequently needed in the management.

Abdominal tuberculosis in a low prevalence country.

OBJECTIVE: Abdominal tuberculosis is a rare disease. The clinical and radiological manifestations are non-specific and the diagnosis is difficult. Our objective was to describe the characteristics and treatment of patients presenting with abdominal tuberculosis in a low-incidence country. PATIENTS AND METHODS: We reviewed the clinical, diagnostic, treatment, and outcome features of patients presenting with abdominal tuberculosis diagnosed by bacteriological and/or histological results and managed in five French university hospitals from January 2000 to December 2009. RESULTS: We included 21 patients. The mean diagnostic delay was 13 months. Twelve patients (57%) came from a low-incidence area and only two had a known immunosuppressed condition. Eighteen patients (86%) presented with abdominal symptoms. The main organs involved were the peritoneum (n=14, 66%), the mesenteric lymph nodes (n=13, 62%), and the bowel (n=7, 33%). Sixteen patients (76%) underwent surgery, including two in an emergency setting. Seventeen patients (81%) received six months or more of anti-tuberculosis treatment. Finally, 16 patients (76%) had a positive outcome. CONCLUSION: New diagnostic procedures, and especially molecular biology, may help diagnose unusual clinical presentations of tuberculosis. Invasive procedures are frequently necessary to obtain samples but also for the treatment of digestive involvement.

A systematic review of hepatic tuberculosis with considerations in human immunodeficiency virus co-infection.

BACKGROUND: Mycobacterium tuberculosis (TB) infection of the liver, known as hepatic TB, is an extrapulmonary manifestation of TB. Hepatic TB has become more prevalent, likely as a result of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic. We sought to review case series to characterize the epidemiology, pathophysiology, clinical features, diagnosis, and treatment of hepatic TB and to comment on the impact of HIV co-infection on these characteristics. METHODS: We conducted a systematic literature search in PubMed and ScienceDirect for articles pertaining to hepatic TB with human subjects from 1960 to July 2013. RESULTS: We obtained data on 618 hepatic TB patients from 14 case series. The most common reported signs and symptoms were hepatomegaly (median: 80%, range: 10-100%), fever (median: 67%, range: 30-100), respiratory symptoms (median: 66%, range: 32-78%), abdominal pain (median: 59.5%, range: 40-83%), and weight loss (median: 57.5%, range: 20-100%). Common laboratory abnormalities were elevated alkaline phosphatase and gamma-glutamyl transferase. Ultrasound and computerized tomography (CT) were sensitive but non-specific. On liver biopsy, smear microscopy for acid-fast bacilli had a median sensitivity of 25% (range: 0-59%), histology of caseating granulomas had a median sensitivity of 68% (range: 14-100%), and polymerase chain reaction for TB had a median sensitivity of 86% (range: 30-100%). Standard anti-tuberculous chemotherapy for 6 to 12 months achieved positive outcomes for nearly all patients with drug-susceptible TB. CONCLUSIONS: Clinicians in TB-endemic regions should maintain a high index of suspicion for hepatic TB in patients presenting with hepatomegaly, fever, respiratory symptoms, and elevated liver enzymes. The most sensitive imaging modality is a CT scan, while the most specific diagnostic modality is a liver biopsy with nucleic acid testing of liver tissue samples. Upon diagnosis, 4-drug anti-TB therapy should promptly be initiated. HIV co-infected patients may have more complex cases and should be closely monitored for complications.

Tuberculosis: experience in a low endemic area Australian tertiary hospital.

BACKGROUND: Abdominal tuberculosis (ATB) poses a significant diagnostic, management, and resource challenge. In Australia, an increasing number of tuberculosis (TB) cases are being reported, and we describe our experience of ATB in an Australian tertiary institution. METHODS: All diagnosed cases of tuberculosis (TB) at the Royal North Shore tertiary hospital campus of the University of Sydney are entered prospectively into a central registry. Cases of ATB encountered between September 1991 and November 2011 were identified and retrospectively reviewed. RESULTS: In all, 841 cases of TB were identified, of which 20 were abdominal (2.4 %). Median age at presentation was 34 years (range: 22-79 years), and 55 % of patients were women. None of the patients were born in Australia and 11 patients were of South Asian origin. The most common presenting symptom was abdominal pain (65 %). Diagnosis was based primarily on histology (90 % sensitivity), and the sensitivity of PCR analysis in this series was low (44 %). Eleven of the patients required laparoscopy or laparotomy. 40 % of cases involved the peritoneum, and disease was also seen in solid organs (liver, spleen, pancreas, adrenal gland) and bowel (esophagus, small bowel, colon). CONCLUSIONS: In our local experience ATB was seen exclusively in the immigrant population. The presentation of ATB varies greatly, necessitating a high index of suspicion within the context of abdominal symptoms in high-risk groups. The role of surgical involvement is indispensable for both diagnosis and management of ATB-related complications. Surgeons should remain mindful of the diagnosis in an age of increasing worldwide incidence.

[Abdominal tuberculosis: a retrospective series of 90 cases]. / Tuberculose abdominale : étude rétrospective de 90 cas.

PURPOSE: The aim of this study was to analyze the clinical, bacteriological, radiological and therapeutic features of abdominal tuberculosis in a series of 90 patients. METHODS: This was a retrospective and descriptive multicentre study of 90 cases of abdominal tuberculosis conducted from June 1997 to June 2008. Diagnosis of tuberculosis was based on bacteriologic evidence in 12 cases, histological evidence in 55 cases and on clinical and radiologic features with favorable outcomes under specific treatment in the 23 remaining cases. RESULTS: Thirty-one patients were male and 59 were female. The mean age of the patients was 41.5 years. Family history of tuberculosis was reported in three cases. Associated risk factors were: diabetes mellitus (five cases), ethylism (one case), post-hepatitis C cirrhosis (one case), systemic lupus erythematosus treated by corticosteroids (one case). Sites of involvement were: peritoneum (78 cases), liver (14 cases), gut (nine cases) and spleen (eight cases). Forty-eight patients (53,3%) had only an abdominal involvement, nine others patients (10%) had an abdominal involvement associated with intra-abdominal lymph nodes, 16 patients (17,8%) had a respiratory involvement (pulmonary, pleural and mediastinal lymph nodes), eight patients (8,8%) presented with an extra-abdominal and extra-respiratory involvement and 10 patients (11,1%) had respiratory and extra-respiratory disease associated with abdominal involvement. Among the 54 patients who underwent laparoscopy or laparotomy, diagnosis was evoked on macroscopic examination in 51. CONCLUSION: Laparoscopy and laparotomy are still helpful for the diagnosis of abdominal tuberculosis, especially in the presence of peritoneal involvement.

Liver tuberculosis in an HIV patient: diagnosis and management.

Hepatic involvement is common in miliary and extra-pulmonary tuberculosis but is usually clinically silent. Therefore, it is rarely diagnosed. We report the case of a patient that presented with prolonged fever and hepatomegaly. Liver biopsy revealed non-necrotizing granulomas that led in turn to the diagnosis of generalized tuberculosis and HIV infection. The patient reported an old untreated tuberculosis and depression of the immune system provoked the reactivation of this old tuberculosis focus. We describe the clinical course of the disease and the challenges associated with the complexity of the treatment. Diagnosis of hepatic tuberculosis requires a high degree of suspicion especially in AIDS patients who show atypical presentations. However, it is a potential curable disease and good results have been obtained with the four drug regimen.

Hepatobiliary tuberculosis: a review of presentations and outcomes.

Hepatobiliary tuberculosis (HTB) is uncommon and can be difficult to diagnose. We present our experience with HTB (over a 10-year period). Fourteen patients were identified from a total of 1888 cases of tuberculosis (TB) infection during this period. Five patients had isolated organ involvement [hepatic (n=3) and biliary (n=2)], and 9 had multiorgan involvement [2 organs (n=7) and 3 organs (n=2)]. The overall annual incidence ranged from 0.0% to 1.05% of all TB infections. Common clinical presentations were weight loss (64%), loss of appetite (64%), abdominal pain (57.1%), fever (50%), jaundice (42.3%), and abdominal distension (14.3%). The median delay from symptom onset to presentation was 40.5 days (range, 7-730 days), and from first presentation to diagnosis was 15 days (range, 1-420 days). Malignancy was initially suspected in 86%. Chest radiographic changes consistent with pulmonary TB were seen in 29% (n=4). Two had active pulmonary TB. Adverse effects of treatment occurred in 42.9%, mainly drug-induced hepatitis and nonspecific gastrointestinal symptoms. Three patients with biliary involvement required long-term biliary stenting. The overall mortality was 14%. In conclusion, HTB is uncommon and is often associated with other organ involvement. Presentation is often delayed, which may lead to significant morbidity and mortality.

[Tuberculosis meningitis in adults: 5 cases]. / Meningite tubercolare negli adulti: 5 casi clinici.

Tuberculosis still represents a problem of public health of worldwide importance. Tuberculosis meningitis is a rare yet serious infectious disease. The diagnosis is mainly clinical and should be considered in a specific epidemiological context. Culture of Mycobacterium tuberculosis from cerebrospinal fluid is required for definitive diagnosis but it cannot always be obtained. In this study we report five cases of tuberculosis meningitis admitted to our Department of Infectious and Tropical Diseases over the last six years, highlighting the main aspects that steered us towards diagnosis and the difficulties we encountered.

Hepatic tuberculosis in absence of disseminated abdominal tuberculosis.

Liver involvement in tuberculosis in absence of miliary tuberculosis is rare. This study was performed to analyse the spectrum and response to treatment of hepatic tuberculosis in the absence of miliary abdominal tuberculosis. Retrospective analysis of seven cases of hepatic tuberculosis without miliary abdominal tuberculosis who presented at the single tertiary referral center were analyzed. All patients presented with fever and hepatomegaly. Five of them had pain in upper abdomen and vomiting. HIV serology was positive in one patient. All patients had normocytic normochromic anaemia, raised erythrocyte sedimentation rate (Mean 65). Mild elevation of liver enzymes and low albumin (Mean 2.4 gm%) with reversal of albumin globulin ratio (Mean 0.6) were seen in all. Two had jaundice. Prothrombin time was normal in all and lactate dehydrogenase values were elevated in all (Mean 794 IU/L). On ultrasonography, 2 had multiple hypodense lesion, 1 had coarse echotexture of liver, 1 had hyperechoic pattern and 3 had just hepatomegaly. Complete resolution of liver lesions on treatment with 4-drug anti-tuberculosis drug chemotherapy was seen. In conclusion, liver tuberculosis has protean manifestations with nonspecific alteration of liver function tests and is best diagnosed on liver biopsy. Overall response to therapy is satisfactory.

Gastrointestinal tuberculosis: an eighteen-patient experience and review.

The diagnosis of gastrointestinal tuberculosis (GITB) is often delayed, increasing the morbidity associated with this treatable condition. In this case series, the clinical presentations and outcomes of 18 patients with GITB are reviewed. Our aim was to elucidate the presenting signs and symptoms of GITB so as to help physicians improve their ability to make this diagnosis. Cases were gathered retrospectively over an 8-year period from Santa Clara Valley Medical Center, San Jose, California. Sources of information included patient records from our TB clinic and our hospital from 1989 to 1997. Of the 18 patients, 16 had a definitive diagnosis of GITB made from histology and/or culture from an abdominal source. In the remaining two patients, a presumptive diagnosis of GITB was made based on the co-occurrence of abdominal signs and symptoms, response to antituberculous therapy, and Mycobacterium tuberculosis identified at a nonabdominal site. The most common clinical presentation was a triad of abdominal pain, fever, and weight loss. This triad was present in 8 of 18 patients. Seven patients presented with two of these signs and symptoms, two had abdominal pain alone, and one presented with other symptomatology. Time to diagnosis ranged from 2 days to 11 months, with a mean time to diagnosis of 50 days. These findings suggest that the diagnosis of GI and hepatic TB is often delayed. Possible reasons for delay include nonspecific signs and symptoms and failure to consider TB in the initial differential diagnosis. Once diagnosed, the outcome of GITB in this series was favorable.

Hepatobiliary tuberculosis.

Tuberculosis is known to involve the liver in different ways. The term hepatobiliary tuberculosis refers to the localized form of hepatic tuberculosis as a distinct clinical entity, with signs and symptoms related to the hepatobiliary tract. Its clinical features and the different diagnostic aids used in its diagnosis are reviewed. Plain abdominal radiographs showing diffuse hepatic calcifications seen in approximately 50% of cases are almost diagnostic for hepatobiliary tuberculosis. Liver biopsies obtained either by ultrasound, computed tomography or laparoscopy, showing caseating granuloma usually establish the diagnosis. In the absence of caseation necrosis, a positive acid-fast bacillus (AFB) or culture for Mycobacterium tuberculosis is needed to establish the diagnosis. A polymerase chain reaction assay for the identification of Mycobacterium tuberculosis in liver biopsy specimens is a new development. Treatment is similar to that used for pulmonary tuberculosis. Quadruple therapy (using four anti-tuberculosis drugs) is recommended, generally for 1 year. For patients with obstructive jaundice, in addition to anti-tuberculous treatment, biliary decompression should be performed either by stent insertion during endoscopic retrograde cholangiopancreatology, by percutaneous transhepatic biliary drainage or by surgical decompression whenever feasible.

The renaissance of abdominal tuberculosis.

During the last decade, abdominal tuberculosis (TB) has experienced a renaissance. The number of cases diagnosed in Western European and North American countries has dramatically increased. The reasons for this are multiple and include the appearance of AIDS as a significant disorder and the increased morbidity of peoples across the world with the migration of many people from areas of high incidence of TB to the West. Recent epidemiological work is reviewed, and its relationship to these changes considered. The distribution of disease along the gastrointestinal tract and in the mesentery is discussed. The frequency of involvement at various sites and the clinical symptoms caused by the disease are reviewed. The need to diagnose abdominal TB in the 1990s is considered in detail in areas where the disease had previously been thought rare.

Hepatic involvement in tuberculosis.

Seventy one cases of pulmonary and extrapulmonary tuberculosis (confirmed by clinical, sputum examination, Skiagram, lymph node or other organ biopsy) and 13 cases of PUO suspected to be tubercular in origin were included in the study. Besides, thorough clinical workup, LFTs and liver biopsy were also done in all cases. LFT alterations were seen in only 5 (7%) cases of tuberculosis while in PUO group, 3 (23%) cases showed deranged LFT. In all, alteration in SGOT/SGPT was most frequent observation. In Liver biopsy, histopathological changes were seen in 63 percent (45 out of 71) of cases of tuberculosis and in 46.16 percent cases of PUO. In tubercular cases, various abnormalities observed were caseating granulomas: 18.30 percent, nonspecific inflammatory infiltration: 25.32 percent, focal Kupffer cell hyperplasia: 11.2 percent and fatty changes: 8.45 percent. Four of the PUO cases, showing Kupffer cell hyperplasia and non-specific inflammatory infiltration responded to antituberculous therapy. Thus it is surmised that though the caseating granuloma is the hallmark of tuberculosis, but nonspecific inflammatory hepatitis and retothelial tubercle nodules may be the forerunner in the evolution of granuloma.