Primary tubercular granulomatous hepatitis presenting as fluctuating jaundice.

Granulomatous hepatitis is an uncommon presentation of tuberculosis (TB). It is even more peculiar to have TB confined to the liver alone with no pulmonary or a disseminated form. In either form, there is the usual presentation of nonprogressive cholestatic jaundice, but no documented case with fluctuating jaundice in the literature was found. In order to highlight this rare presentation aiding the right diagnosis, we present one such case of a 46-year-old woman with no known comorbidities, who complained of fluctuating and painless type of jaundice, associated with fatiguability, pruritus, and weight loss. Preliminary blood investigations showed anemia and cholestatic pattern of jaundice. Ultrasonography and computed tomography imaging showed hepatomegaly with heterogeneous texture. Magnetic resonance cholangiopancreatography further revealed features of cholecystitis with hepatic ducts near proximal common bile duct showing postinflammatory change. The periampullary region was normal. Sputum acid-fast staining and cartridge-based nucleic acid amplification test were negative. Eventually, liver biopsy was done which showed caseating granulomas with Langhans giant cells. The tissue was abundant in acid-fast bacilli. The patient was started on a 9-month course of first-line Antitubercular treatment (ATT) and responded well. Fluctuating jaundice is a rare and undocumented presentation of primary hepatic TB and can cause diagnostic dilemmas.

Primary isolated hepatic tuberculosis mimicking small hepatocellular carcinoma: A case report.

RATIONALE: Mycobacterium tuberculosis (TB) remains a serious threat in developing countries. Primary isolated hepatic tuberculosis is extremely rare. Because of its non-specific imaging features, noninvasive preoperative imaging diagnosis of isolated hepatic tuberculoma remains challenging. PATIENT CONCERNS: A 48-year-old man was admitted to our hospital due for suspected liver neoplasm during health examination. DIAGNOSES: The tests for blood, liver function, and tumor markers were within normal range. Preoperative ultrasonography (US) showed a hypoechoic lesion with a longitudinal diameter of 2.5 cm in segment six of liver. It exhibited early arterial phase hyperenhancement and late arterial phase rapid washout in contrast-enhanced US. It demonstrated hyperintensity in T2-weighted magnetic resonance imaging and partly restricted diffusion in diffusion-weighted imaging. For this nodule, the preoperative diagnosis was small hepatocellular carcinoma (HCC). INTERVENTIONS: Laparoscopic hepatectomy was performed. Intraoperative extensive adhesion in the abdominal cavity and liver was found. The lesion had undergone expansive growth. OUTCOMES: Microscopically, a granuloma with some necrosis was detected. With both acid-fast staining and TB fragment polymerase chain reaction showing positive results, TB was the final histology diagnosis. After surgery, the patient declined any anti-TB medication. During the follow-up, he had no symptoms. In the sixth month after surgery, he underwent an upper abdominal US. It showed no lesions in the liver. LESSONS: Because of non-specific imaging findings and non-specific symptoms, a diagnosis of isolated hepatic TB is difficult to make, especially for small lesions. A diagnosis of HCC should be made cautiously when small isolated lesions in the liver are encountered, especially in patients without a history of hepatitis and with negative tumor markers.

Diagnostic Utility and Impact on Clinical Decision Making of Focused Assessment With Sonography for HIV-Associated Tuberculosis in Malawi: A Prospective Cohort Study.

BACKGROUND: The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi. METHODS: Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol. RESULTS: A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P<.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%. CONCLUSION: In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.

Hepatosplenic Tuberculosis on Pretherapy and Posttherapy FDG PET/CT.

A 65-year-old woman underwent FDG PET/CT for presumed hepatosplenic malignancy suggested by an abdominal CT. The images revealed multiple foci of intense FDG activity in both the liver and the spleen. However, a splenic biopsy result revealed no malignant cells, and either tuberculosis or sarcoidosis was proposed. Following an incomplete antituberculosis therapy, a repeat FDG PET/CT showed resolution of the abnormal activity in the liver and the spleen.

Isolated hepatic tuberculosis presenting as hydatid cyst.

Primary hepatic tuberculosis is a rare manifestation of extra-pulmonary tuberculosis even in highly endemic countries. The incidence of hepatic tuberculosis has increased in the recent years due to high prevalence of HIV/AIDS. Radiological imaging is an important tool for making the diagnosis, but often the imaging findings are non-specific and may mimic other benign or malignant hepatic diseases. We report a case of 54-year-old woman who was detected to have hepatic mass on radiological imaging which was misdiagnosed as hydatid cyst. Intraoperatively, the characteristic features of hydatid cyst were absent. A partial resection of this cystic mass was performed. Histopathological examination of the resected specimen revealed granulomatous inflammation consisting of histiocytes and Langhans-type giant cells surrounded by lymphocytes suggestive of hepatic tuberculosis. The patient was administered antitubercular therapy for 1 year. Repeat imaging on follow up showed disappearance of the hepatic lesion.

Rare and unusual case of hepatic and disseminated tuberculosis in an immunocompetent patient.

Mycobacterium tuberculosis complex disease (tuberculosis (TB)) of the liver is rare and liver abscesses as a result are even rarer. In an immunocompetent individual, the disease tends to be localised. To the best of our knowledge, we report one of the most severe TB involvements of the liver in an immunocompetent individual. A young woman with a history of previous TB infection, presented in septic shock. Scans showed a liver filled with possible abscesses, one of which was aspirated and confirmed TB. Multiple HIV tests were negative but she remained lymphopaenic. Although she improved substantially with anti-tuberculous treatment, she later developed non-tuberculous central nervous system disease that we were unable to fully explain. Despite a stormy recovery period, she continues to do well.

Primary hepatic tuberculosis masquerading as intrahepatic cholangiocarcinoma.

Abdominal tuberculosis is a common clinical entity in Indian subcontinent; however, hepatic tuberculosis in the absence of miliary abdominal tuberculosis is restricted to the case reports and small case series in English literature. It mimics common liver diseases like liver abscess and tumours. We report a case of 38 years old male presenting with abdominal pain, loss of appetite and weight initially misdiagnosed as intrahepatic cholangiocarcinoma on magnetic resonance imaging and FNAC of the lesion but later diagnosed as a case of hepatic tuberculosis on post operative histopathology specimen. It is important to consider tuberculosis in the differential diagnosis when suspecting lymphoproliferative or metastatic diseases in a patient with vague symptoms.

Common and uncommon imaging features of abdominal tuberculosis.

Despite the advances in the medical care, tuberculosis (TB) still remains an important health problem. This is particularly relevant to the developing countries as well as the immunocompromised population in the developed world. Multidrug resistance poses another challenge and may be responsible for increasing incidence of TB, to some extent. The respiratory system is the most commonly involved, although any organ system may be affected. Abdominal involvement occurs in 11-12% of the patients with extrapulmonary TB. The clinical features of abdominal TB are nonspecific. Imaging plays an important role in the diagnosis of abdominal TB. Although a few imaging features strongly favour the possibility of TB, abdominal TB is a greater masquerader. In this review, we highlight the entire spectrum of the manifestations of abdominal tuberculosis (excluding the genitourinary involvement) with an emphasis on imaging findings.

Computed tomographic features of abdominal tuberculosis: unmask the impersonator!

PURPOSE: Abdominal tuberculosis (ATB) mimics various infectious, inflammatory, and neoplastic conditions and hence requires a high index of suspicion for accurate diagnosis, especially in low prevalence areas. It is difficult to consistently establish a histopathological diagnosis of ATB which underlines the importance of supportive evidences for institution of prompt empirical therapy to prevent associated morbidity and mortality. METHODS: We retrospectively evaluated clinical and imaging features of 105 ATB cases and classified their CT findings based on peritoneal, lymph node, bowel, and solid organ involvement. Concomitant pulmonary and extra-pulmonary involvement was assessed. RESULTS: Abdominal pain (78.1%) followed by fever (42.9%) were the commonest presenting symptoms. Peritoneal TB (77.14%) most commonly presented with a mix of ascites (49.38%), peritoneal (28.40%), and omental involvement (27.16%). Lymphadenopathy (57.1%) most commonly presented as necrotic nodes (81.67%) at mesenteric, peripancreatic, periportal, and upper paraaortic regions. Commonest site of bowel involvement (cumulative of 62.85%) was ileocecal region, with the commonest pattern of involvement being circumferential bowel wall thickening without bowel stratification with mild luminal narrowing. Hepatic (13.33%) and splenic (16.2%) involvement predominantly presented as multiple microabscesses. Adrenal and pancreatic involvement was noted in 4.7% and 1.9% of patients, respectively. 38.1% patients showed concomitant pulmonary and extra-pulmonary TB. CONCLUSION: ATB has varied radiological features; however, peritoneal involvement in the form of mild ascites, smooth peritoneal thickening, smudgy omentum, multi-focal bowel involvement, necrotic nodes, and multiple visceral microabscesses point towards a diagnosis of ATB in appropriate clinical setting.

Isolated hepatobiliary tuberculosis: a diagnostic challenge.

Hepatobiliary system involvement is frequently seen as part of disseminated tubercular infection. But primary isolated hepatobiliary tuberculosis with no evidence of tuberculosis elsewhere in the body is extremely rare. Isolated hepatobiliary tuberculosis can cause diagnostic dilemma as the clinical, laboratory and imaging features are non-specific in majority of the cases. We report the case of a 50-year-old woman who presented with hepatobiliary tuberculosis with no pulmonary or extra hepatic involvement. Liver function tests were abnormal and ultrasonography (USG), CT and MR cholangiopancreatography showed multiple focal lesions in the liver. The diagnosis of tuberculosis was confirmed by a USG-guided biopsy of the liver lesions. In endemic regions with the presence of supportive imaging findings, in the appropriate clinical setting, the possibility of hepatic tuberculosis should be considered and diagnosis has to be confirmed with histopathological examination.

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.

Localized hepatic tuberculosis presenting as severe hypercalcemia.

Hypercalcemia might present itself in association with granulomatous diseases such as tuberculosis. We report a rare case of a 62-year-old man with hypercalcemia due to hepatic tuberculosis. The diagnosis was based on laparoscopic and a histopathological examination. After treatment with anti-tuberculosis medication, the patient's serum calcium levels were within normal limits. Tuberculosis needs to be excluded as a diagnosis in any febrile patient with hypercalcemia, especially in countries where tuberculosis is endemic.

Imaging appearances of hepatic tuberculosis: experience with 12 patients.

AIM: To review computed tomography (CT), ultrasound (US), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiogram (PTC) appearances and their diagnostic value in hepatic tuberculosis. MATERIALS AND METHODS: The imaging studies for 12 patients with biopsy-proven hepatic tuberculosis from January 2012 till March 2014 were reviewed retrospectively. These cases were confirmed via ultrasound-guided biopsy. RESULTS: The patients were aged 24-72 years. Four patients had parenchymal tuberculosis only and eight patients had mixed parenchymal and biliary duct involvement. The parenchymal tuberculosis patients showed poorly enhancing, hypodense nodules on CT with central calcification and adjacent dilated intrahepatic ducts. Most patients had multiple lesions except for two patients with a single lesion. The size of the lesions ranged from 0.5 to 6 cm. Seven patients with biliary duct involvement showed a hilar strictures involving the intrahepatic ducts and common bile duct. Nine of the patients showed hilar stricture with atrophy of the ipsilateral lobe of the liver and compensatory hypertrophy of the contralateral lobe. Hepatolithiasis was seen in five patients. Tuberculous lung involvement was seen in seven patients. CONCLUSION: The presence of calcified and hypodense nodules with biliary duct dilatation associated with lobar atrophy were the most consistent features of hepatic tuberculosis, especially in the presence of active lung disease.

Extrapulmonary involvement in pediatric tuberculosis.

Tuberculosis in childhood is clinically challenging, but it is a preventable and treatable disease. Risk factors depend on age and immunity status. The most common form of pediatric tuberculosis is pulmonary disease, which comprises more than half of the cases. Other forms make up the extrapulmonary tuberculosis that involves infection of the lymph nodes, central nervous system, gastrointestinal system, hepatobiliary tree, and renal and musculoskeletal systems. Knowledge of the imaging characteristics of pediatric tuberculosis provides clues to diagnosis. This article aims to review the imaging characteristics of common sites for extrapulmonary tuberculous involvement in children.