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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 31-33

A rare case of hepatic tuberculoma in an immunocompetent patient


Department of Pulmonary Medicine, Government Stanley Medical College, Chennai, Tamil Nadu, India

Date of Submission06-Apr-2022
Date of Decision03-May-2022
Date of Acceptance20-May-2022
Date of Web Publication12-Aug-2022

Correspondence Address:
Hema Murugesan
Senior Resident, Department of Pulmonary Medicine, Government Stanley Medical College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_7_22

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  Abstract 


Hepatic tuberculoma is an uncommon form of extrapulmonary tuberculosis (TB). It is usually a part of disseminated disease such as miliary TB. Localized TB of the liver in the form of macronodular tuberculoma or an abscess is rare.[1] Clinicians should be aware of the possibility of tuberculous infection in all patients who have nonresolving liver abscesses, particularly in regions with high prevalence. Presented here is a case of an immunocompetent patient with tuberculoma of the liver, which was diagnosed by percutaneous ultrasonography-guided liver biopsy.

Keywords: Antitubercular therapy, granuloma, hepatotoxicity, liver, tuberculosis


How to cite this article:
Murugesan H, Padmanathan H, Selvam R, Kumaran S, Viswanathan VK. A rare case of hepatic tuberculoma in an immunocompetent patient. J Assoc Pulmonologist Tamilnadu 2022;5:31-3

How to cite this URL:
Murugesan H, Padmanathan H, Selvam R, Kumaran S, Viswanathan VK. A rare case of hepatic tuberculoma in an immunocompetent patient. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2022 Oct 3];5:31-3. Available from: http://www.japt.com/text.asp?2022/5/1/31/353746




  Introduction Top


Tuberculosis (TB) infection is still common today and remains an important cause of morbidity and mortality . Abdominal TB is one of the most prevalent forms of extrapulmonary manifestation . Hepatic involvement is uncommon and is categorized into 5 types: miliary, abscess, nodule, biliary invasion and serosal invasion. The manifestations range from abscesses and tuberculomas to hepatic calcifications. The manifestations can be non-specific and mimic many conditions. Ultrasonography (US) and computed tomography (CT) are the main radiological tools used for diagnosis.


  Case Report Top


A 71-year-old male, ex-alcoholic, known case of hypertension, old Cerebrovascular accident (CVA) in 2011, presented with complaints of abdominal pain and loss of appetite of 2-week duration. Ultrasonography (USG) of the abdomen showed two ill-defined space-occupying lesions measuring 4.0 cm × 3.5 cm in the left lobe and 4.2 cm × 3.3 cm in the right lobe which was reported as mass or liver abscess, mild splenomegaly, and minimal ascites. The patient was advised with contrast-enhanced computed tomography (CECT) abdomen by sonologist.

CECT of the abdomen [Figure 1] shows hepatomegaly, multiple heterogeneously enhancing hypodense lesion in the right lobe features suggestive of secondaries.
Figure 1: CECT of the abdomen shows hepatomegaly, multiple heterogeneously enhancing hypodense lesion in the right lobe of liver features suggestive of secondaries

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The patient underwent upper gastrointestinal endoscopy which showed a large hiatus hernia, Grade II esophagitis, and antral gastritis.

Further fluorodeoxyglucose positron emission tomography CT whole-body scan is highly suspicious for hepatic and splenic metastasis [Figure 2] along with mediastinal adenopathy [Figure 3]. Possibility of primary: one of the liver lesions/unknown primaries.
Figure 2: Fluorodeoxyglucose positron emission tomography CT whole-body scan is highly suspicious for hepatic and splenic metastasis

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Figure 3: Fluorodeoxyglucose positron emission tomography CT whole-body scan showing mediastinal adenopathy

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USG-guided tru-cut biopsy from the liver lesion was done and it showed necrotizing granulomatous inflammation suggestive of tuberculosis (TB).

The patient was started on standard four-drug anti-TB treatment with isoniazid (INH), rifampicin, ethambutol, and pyrazinamide but developed hepatotoxicity within 2 weeks and hence was shifted to a less hepatotoxic regimen which is used in patients with chronic liver diseases with INH, ethambutol, and levofloxacin which he was tolerating well monitored with serial liver function test.


  Discussion Top


TB is an infection which mainly affects the lungs. Extrapulmonary disease can occur in 15%–20% of the patients, and <1% accounts for hepatic TB (HTB).[1],[2] HTB can appear as a result of miliary TB or as a primary localized lesion occurring in 50%–80% of cases due to the dissemination of TB bacilli through the hepatic artery.[3]

Autopsy studies during the latter half of the 19th century and early 20th century demonstrated granulomas and a variety of other lesions in the livers of patients dying with tuberculosis.[4]

HTB is classified into three types which include the miliary TB derived from generalized infection, the primary hepatic miliary TB, and the rarest nodular lesion named tuberculoma.[5],[6]

Tuberculomas may occur as solitary or multiple nodules in patients with primary miliary TB of the liver or secondary to the reactivation of hepatic foci of infection. These lesions may have a diameter of up to 12 cm and may undergo central caseation leading to abscess formation.[7]

No specific symptoms can be related to the hepatic abnormalities in pulmonary TB, although of course, the constitutional symptoms associated with the underlying TB (fever, chills, fatigue, abdominal pain, and weight loss) are common.[8]

The various causes of lesions in the liver include:[9]

  1. Autoimmune diseases: Sarcoidosis and polymyalgia rheumatic
  2. Vasculitides: Polyarteritis nodosa and Churg‒Strauss syndrome
  3. Infection


    1. Bacterial: TB, brucellosis and listeriosis
    2. Fungal: Histoplasmosis, coccidioidomycosis, and Cryptococcus
    3. Viral: cytomegalovirus, Epstein–Barr virus, and hepatitis A, B, and C.


  4. Drugs: Nitrofurantoin, phenytoin, and allopurinol
  5. Malignancy: Hodgkin's lymphoma, renal cell carcinoma, and hepatic metastasis.


Among the first-line drugs used for the treatment of TB, INH, rifampicin, and pyrazinamide can cause hepatotoxicity in 3%–25% of cases, of which 0.1%–0.25% with INH and 0.08%–2% with rifampicin.[9]

HTB can be managed effectively with ATT if diagnosed in time and if left untreated can lead to death.

The USG can demonstrate mostly hypoechoic lesions, whereas the typical CT finding is the heterogeneity of the lesions which vary from hypodense to hyperdense.[10] On T1-weighted imaging magnetic resonance imaging, the lesions are hypointense, whereas on T2-weighted imaging, the lesions appear isointense and hyperintense with enhancement after contrast administration.[11],[12]

The use of needle biopsy of the liver to demonstrate tuberculous lesions has made the procedure a valuable tool for the diagnosis of the disease, especially in cases of cryptic miliary TB without recognized pulmonary involvement.[13]

Differential diagnosis:

  1. Macronodular hepatic granuloma ‒ metastases, primary malignancy, and abscess
  2. Micronodular hepatic granuloma ‒ lymphoma, sarcoidosis, metastases, fungal and infections
  3. It has been recommended that patients with isolated HTB be treated with standard regimens despite the potential hepatotoxicity of the regimen.[14] Our case posed a challenge due to elevated bilirubin levels which warranted modification of ATT.



  Conclusion Top


Hepatic tuberculoma is a rare entity with no specific symptoms, signs, laboratory, or imaging findings. It's hallmark is a central caseating necrotic granuloma with or without acid-fast bacilli. Hepatic tuberculoma can be managed effectively with ATT if diagnosed in time and if left untreated can lead to death.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mert A, Ozaras R, Tabak F, Ozturk R, Bilir M. Localized hepatic tuberculosis. Eur J Intern Med 2003;14:511-2.  Back to cited text no. 1
    
2.
Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ 1999;160:1597-603.  Back to cited text no. 2
    
3.
Chien RN, Lin PY, Liaw YF. Hepatic tuberculosis: comparison of miliary and local form. Infection 1995;23:5-8.  Back to cited text no. 3
    
4.
Ullom JT. The liver in tuberculosis. The American Journal of the Medical Sciences (1827-1924) 1909;137:694.  Back to cited text no. 4
    
5.
Rolleston HD, McNee JW. Disease of the Liver, Gall Bladder and Bile Ducts. Vol. 3. London: MacMillan and Co; 1929. p. 884.  Back to cited text no. 5
    
6.
Spiegel CT, Tuazon CU. Tuberculous liver abscess. Tubercle 1984;65:127-31.  Back to cited text no. 6
    
7.
Essop AR, Segal I, Posen J, Noormohamed N. Tuberculous abscess of the liver. A case report. S Afr Med J 1983;63:825-6.  Back to cited text no. 7
    
8.
Guckian JC, Perry JE. Granulomatous hepatitis. An analysis of 63 cases and review of the literature. Ann Intern Med 1966;65:1081-100.  Back to cited text no. 8
    
9.
Saukkonen JJ, Cohn DL, Jasmer RM, Schenker S, Jereb JA, Nolan CM, et al. An official ATS statement: Hepatotoxicity of antituberculosis therapy. Am J Respir Crit Care Med 2006;174:935-52.  Back to cited text no. 9
    
10.
Yu RS, Zhang SZ, Wu JJ, Li RF. Imaging diagnosis of 12 patients with hepatic tuberculosis. World J Gastroenterol 2004;10:1639-42.  Back to cited text no. 10
    
11.
Fan ZM, Zeng QY, Huo JW, Bai L, Liu ZS, Luo LF, et al. Macronodular multi-organs tuberculoma: CT and MR appearances. J Gastroenterol 1998;33:285-8.  Back to cited text no. 11
    
12.
Kawamori Y, Matsui O, Kitagawa K, Kadoya M, Takashima T, Yamahana T, et al. Macronodular tuberculoma of the liver: CT and MR findings. Am J Roentgenol 1992;158:311-3.  Back to cited text no. 12
    
13.
Mansuy MM, Seiferth WJ. Miliary tuberculosis of the liver: Liver biopsy as an adjunct to diagnosis. Am J Med Sci 1950;220:293-7.  Back to cited text no. 13
    
14.
Sonika U, Kar P. Tuberculosis and liver disease: Management issues. Trop Gastroenterol 2012;33:102-6.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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