Case Report Hepatic TB

7/27/2019 Case Report Hepatic TB

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Hepatic TBCase 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 178mg/L),

-an elevated alkaline phosphatase (153 IU/L).



Contrast enhanced

abdominal CT scan-6 x 5 cm mixedattenuating lesionin the left lobe,

-4cm lesion in theright lobe of theliver.

Abdominal ultrasound: a 6.5-cm

heterogenous mass in the left lobe of the

liver suggestive of HCC.

The appearances:

suggestive of either lymphoma or HCC.



Serum tumour markers

AFP, CEA, CA 19-9: were

normal



HFL by US &|or

AFP > 200

M.

Triphasic

Helical CT

Conclusive*

Not conclusive

Tumor size

>

2

cm

AFP>

200 AFP<

200

Liver biopsy

<

2

cm

II- Diagnosis

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

venous phase) Samy zaky



Histology revealedgranulomatous

inflammation

associated withLanghans 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)

a guided liver biopsy:



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: noevidence 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 inup to 80% of disseminated casesof TB.

Isolated tuberculous involvement of the liver is considered rare (lowO2 tension within the liver)

Primary hepatic TB in absence of immunocompromise is extremelyrare.



Hepatic TB

(a) Miliary TB;

(b) pulmonary TB with hepaticinvolvement;

(c) primary liver TB;

(d) focal tuberculoma or abscess; or

(e) tuberculous cholangitis.

Hepatic TB has been classified by

Levine into:



• Tuberculous cholangitis may

present with jaundice & fever.• Focal liver abscess: right upper

quadrant abdominal pain, fever,

night sweats, anorexia, and weightloss.

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 diagnosticchallenge, with many DD, including primaryHCC.

• US: Hypoechoic nodules are usually seen.

• CT findings: usually reveal a round hypodenselesion 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-occupyinglesions of the liver .



• The histologic findings often achievethe 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 alsobeen advocated.

• Mustard and colleagues suggested featuresassociated with successful drainage included:

(1) unilocular abscess;(2) safe access route for instillation of drainagecatheter; and

(3) a sterile uncontaminated compartment.



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Case Report Hepatic TB