Isolated giant tuberculomata of the liver detected by computed tomography

Isolated hepatic tuberculosis associated with portal vein thrombosis and hepatitis B virus coinfection: A case report and review of the literature

BACKGROUND

While tuberculosis (TB) itself is a common disease, isolated TB of the liver is a rare entity. Tubercular involvement of the liver is more commonly a part of a disseminated disease of the hepatic parenchyma. In contrast, isolated hepatic TB spread through the portal vein from the gastrointestinal tract is seldom encountered in clinical practice, with only a few sporadic cases and short series available in the current literature. Vascular complications, such as portal vein thrombosis (PVT), have rarely been reported previously.

CASE SUMMARY

A 22-year-old man was hospitalized with complaints of a 3-mo history of fever and weight loss of approximately 10 kg. He had a 10-year hepatitis B virus (HBV) infection in his medical history. Contrast-enhanced computed tomography (CECT) confirmed hepatosplenomegaly, with hypodensity of the right lobe of the liver and 2.1 cm thrombosis of the right branch of the portal vein. A liver biopsy showed epithelioid granulomas with a background of caseating necrosis. Ziehl-Nelson staining showed acid-fast bacilli within the granulomas. The patient was diagnosed with isolated hepatic TB with PVT. Anti-TB therapy (ATT), including isoniazid, rifapentine, ethambutol, and pyrazinamide, was administered. Along with ATT, the patient was treated with entecavir as an antiviral medication against HBV and dabigatran as an anticoagulant. He remained asymptomatic, and follow-up sonography of the abdomen at 4 mo showed complete resolution of the PVT.

CONCLUSION

Upon diagnosis of hepatic TB associated with PVT and HBV coinfection, ATT and anticoagulants should be initiated to prevent subsequent portal hypertension. Antiviral therapy against HBV should also be administered to prevent severe hepatic injury.

Floral-like enhancement might reflect an active liver tuberculous lesion to avoid systemic hematogenous dissemination by surgery: A case report

After primary dissemination of Mycobacterium tuberculosis bacillus infection that is localized in liver, disease progression and changes to immune function in the body occur. Various forms of tuberculosis, including granuloma, caseous necrosis, liquefactive necrosis, fibrosis, and calcification, occur that could be presented at different stages, and imaging examination shows findings that are consistent with these stages. Not all liver tuberculosis patients are suitable for liver resection, and preoperative imaging examination and pathological immunohistochemical results could be used to determine whether tuberculosis was active, avoid unnecessary liver resection, and prevent the postoperative spread of tuberculosis. Here, we reported a case of miliary tuberculosis, pelvic tuberculosis, and tuberculous abscess of the thigh muscle in a 51-year-old man after liver lesion resection. The liver lesion was confirmed to be tuberculosis by surgical pathology, which is rare and has not been previously reported. The purpose of this case report is to remind radiologists of the importance of the floral-like enhancement and to estimate whether liver tuberculosis is active. This will help to guide clinicians to determine the timing of surgery, avoid unnecessary liver resection, and avoid hematogenous transmission.

Contrast-Enhanced Ultrasound LI-RADS LR-5 in Hepatic Tuberculosis: Case Report and Literature Review of Imaging Features

Background: The liver is involved in disseminated tuberculosis in more than 80% of cases while primary liver involvement is rare, representing <1% of all cases. Hepatic tuberculosis (TB) can be treated by conventional anti-TB therapy; however, diagnosing this disease remains a challenge. The diagnosis might be particularly difficult in patients with a single liver lesion that could be misdiagnosed as a tumor or other focal liver lesions. Although computed tomography (CT) and magnetic resonance imaging (MRI) findings have been described, there is a paucity of literature on contrast-enhanced ultrasound (CEUS) features of hepatic TB. Case Summary: herein, we describe a case of a patient with tuberculous lymphadenopathy and chronic Hepatitis C Virus (HCV)-related liver disease who developed a single macronodular hepatic TB lesion. Due to the finding of a hepatocellular carcinoma (HCC) highly suggestive CEUS pattern, specifically a LR5 category according to the Liver Imaging Reporting and Data System (LI-RADS), and a good response to antitubercular therapy, a non-invasive diagnosis of HCC was made, and the patient underwent liver resection. We also review the published literature on imaging features of hepatic TB and discuss the diagnostic challenge represented by hepatic TB when occurs as a single focal liver lesion. Conclusions: this report shows for the first time that the CEUS pattern of hepatic TB might be misinterpreted as HCC and specific imaging features are lacking. Personal history and epidemiological data are mandatory in interpreting CEUS findings of a focal liver lesion even when the imaging pattern is highly suggestive of HCC.

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.

Tuberculosis of the gastrointestinal tract and associated viscera

Tuberculosis involvement of the gastrointestinal tract, peritoneum, and associated viscera is an uncommon but well described entity. While peritoneal tuberculosis and tuberculous enteritis are more common, involvement of the esophagus, stomach, colon, rectum, anus, liver, bile ducts, gallbladder, and pancreas can occur. Diagnosis is challenging as cases often mimic neoplasm or inflammatory bowel disease. In this review we outline the pathogenesis, clinical presentation, diagnostic testing, and treatment strategies pertaining to such cases.

Tuberculosis as an Etiological Factor in Liver Abscess in Adults

Background. Tuberculosis of the liver without active pulmonary or miliary tuberculosis is considered as an uncommon diagnosis. The aim of the present study was to determine the etiological role of tuberculosis in adult patients presenting with features of liver abscess. Methods. A total of 40 patients with liver abscess were included in the study. The liver abscess aspirate was subjected to microscopy, culture, and polymerase chain reaction to determine the role of tuberculosis as an etiological factor in liver abscess. Results. Of the 40 patients enrolled, 25% (10/40) were diagnosed with having tubercular liver abscess. In a total of 40 specimens, 2.5% (1/40) were positive for acid fast bacilli by Ziehl-Neelsen method, while 10% (4/40) were positive for M. tuberculosis by culture using BACTEC 460 and the yield increased to 25% (10/40) by polymerase chain reaction for M. tuberculosis. Conclusion. 25% of the patients presenting with liver abscess had tubercular etiology without features of active pulmonary or miliary tuberculosis. Liver can act as the primary site of involvement in the absence of activity elsewhere in the body. Tuberculosis should be considered as an important differential diagnosis of liver abscess irrespective of evidence of active tuberculosis elsewhere in the body.

Necrotizing granulomatous inflammation of the liver

A 73-year-old patient with necrotizing granulomatous inflammation of the liver is presented. The computed tomography demonstrated 2 hypodense tumors with progressive enhancement in the liver. They became nearly isodense to the normal hepatic parenchyma on the delayed phase.

Hepatic tuberculosis: a multimodality imaging review

OBJECTIVES

We aim to illustrate the multimodal imaging spectrum of hepatic involvement in tuberculosis (TB). Whilst disseminated tuberculosis on imaging typically manifests as multiple small nodular lesions scattered in the liver parenchyma, isolated hepatic tuberculosis remains a rare and intriguing entity.

METHODS

Indubitably, imaging is the mainstay for detection of tubercular hepatic lesions which display a broad spectrum of imaging manifestations on different modalities. While sonography and computed tomography (CT) findings have been described in some detail, there is a paucity of literature on magnetic resonance imaging (MRI) features. Due to a significant overlap with other commoner and similar appearing hepatic lesions, hepatic tuberculosis is often either misdiagnosed or labelled as indeterminate lesions. This article is a compendium of cases highlighting the spectrum of imaging patterns that can be encountered in patients with isolated primary hepatic tuberculosis as well as disseminated (secondary) disease. Rare patterns of primary disease such as tubercular cholangitis, hypervascular liver masses, and those with vascular complications are also illustrated and discussed.

CONCLUSIONS

Imaging plays a valuable role in the detection of tubercular hepatic lesions. Also, imaging can be helpful in their characterisation and for assessing associated complications.

TEACHING POINTS

• Hepatic TB has myriad imaging manifestations and is often confounded with neoplastic lesions. • Imaging patterns include miliary TB, macronodular TB, serohepatic TB and tubercular cholangitis. • Concurrent splenic, nodal or pulmonary involvements are helpful pointers towards the diagnosis. • Miliary calcifications along the bile ducts are characteristic of tubercular cholangitis. • Histological/microbiological confirmation is often necessary to confirm the diagnosis.

Hepatic tuberculosis mimicking metastasis in a case of carcinoma sigmoid colon

Tuberculosis (TB) presenting as isolated liver mass without clinical evidence of TB is difficult to diagnose preoperatively and is usually mimicked by primary or metastatic carcinoma of the liver. Hepatic TB associated with carcinoma colon is a rare association which has very rarely been reported in the literature. This case illustrates the diagnostic difficulties of hepatic TB and the need to consider it in the differential diagnosis of hepatic nodular lesions in carcinoma colon patients. Here, we report a case of 48-year-old female who presented in the casualty with features of acute intestinal obstruction. Preoperatively a mass was seen at the hepatic flexure along with three lesions in the liver presumed to be metastatic in origin. However, histopathology of the mass revealed adenocarcinoma colon and the liver lesion proved to be hepatic TB. We wish to highlight that on encountering a hepatic lesion in a carcinoma colon patient the possibility of hepatic TB should also be kept in mind apart from the obvious possibility of metastasis especially in an endemic country like India.

Attachment in the doctor-patient relationship in general practice: a qualitative study

OBJECTIVE

To explore why interpersonal continuity with a regular doctor is valuable to patients.

DESIGN, SETTING, AND SUBJECTS

A qualitative study based on 22 interviews with patients, 12 who saw their regular general practitioner (GP) and 10 who saw an unfamiliar GP. The patients were selected after an observed consultation and sampled purposively according to reason for encounter, age, and sex. The research question was answered by means of psychological theory.

RESULTS

A need for attachment was a central issue for the understanding of the value of interpersonal continuity for patients. The patients explained that they preferred to create a personal relationship with their GP and the majority expressed a degree of vulnerability in the doctor-patient relationship. The more sick or worried they were the more vulnerable and the more in need of a regular GP. Furthermore, patients stated that it was difficult for them to change GP even if they had a poor relationship.

CONCLUSION

Attachment theory may provide an explanation for patients' need to see a regular GP. The vulnerability of being a patient creates a need for attachment to a caregiver. This need is fundamental and is activated in adults when they are sick or scared.

Tuberculoma of the liver

We report an isolated giant solid macronodular tuberculoma in an 8-year-old boy. A large-space-occupying lesion in the right lobe with nodular surface and hard consistency mimicked liver malignancy. This case is unusual as the ultrasonography, computed tomography scan, and aspiration cytology were all suggestive of a malignant tumor. Laparotomy confirmed a 15 × 10 cm nodular tumor present in the right lobe of liver. The segments 5, 6, 7, and 8 were excised. The histopathology revealed tuberculosis.

The nodular form of hepatic tuberculosis: a review with five additional new cases

BACKGROUND

Tuberculosis presenting as an isolated liver tumour, without active pulmonary or miliary tuberculosis, or other clinical evidence of tuberculosis, is distinctly rare. A greater awareness of this rare clinical entity may prevent needless surgical intervention.

AIMS

To help characterise this distinctly rare presentation of tuberculosis, five new cases are presented, together with a review of the world literature. The clinical, laboratory, radiological, and pathological features of these patients are described.

METHODS

Polymerase chain reaction (PCR) assay of the liver tissue was carried out in all cases to confirm an aetiological diagnosis of Mycobacterium tuberculosis infection.

RESULTS

All five patients (44-71 years old; two women, three men) underwent surgery, and had a preoperative diagnosis of malignant hepatic neoplasm and a postoperative histological diagnosis of chronic granulomatous inflammation, suggestive of tuberculosis. None of them had a known previous history of tuberculosis. All of them were positive for M tuberculosis by PCR analysis of the liver tissue.

CONCLUSIONS

This report illustrates the difficulty in reaching a correct preoperative diagnosis. It is usually unsuspected and confused with primary or metastatic carcinoma of the liver, especially when it coexists with other malignancies. A high index of suspicion is required for diagnosis, which can be made only by histological and bacteriological studies, and PCR analysis.

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.

Tuberculoma of the liver presenting as a hyperechoic mass on ultrasound

An unusual case of hepatic macronodular tuberculoma is presented. As demonstrated by CT, the tuberculoma replaced the entire lateral segment of the left lobe of liver and resembled an infiltrative tumour. On ultrasound, the tuberculoma presented as a hyperechoic lesion, in contrast to a round hypoechoic mass which is usually seen in this condition. Hepatic macronodular tuberculomas are not uncommonly misdiagnosed as primary or secondary liver tumours by imaging studies, and the definite diagnosis is usually established by liver biopsy. The prognosis of hepatic macronodular tuberculoma is usually very good with effective treatment.

A radiological study of abdominal tuberculosis in a Saudi population, with special reference to ultrasound and computed tomography

The radiological appearances of abdominal tuberculosis are presented, which includes peritoneal, liver, spleen and pancreatic disease, but excludes renal and musculoskeletal involvement. Twenty-three patients were studied, 12 of whom had TB peritonitis. Barium studies remain valuable in gastrointestinal tract disease but for peritoneal, splenic, hepatic and pancreatic disease, ultrasound and computed tomography are indicated. Their diagnostic value is further enhanced by guided aspiration and biopsy techniques.

CT appearances in macronodular hepatosplenic tuberculosis: a review with five additional new cases

Pseudotumoral or macronodular hepatosplenic tuberculosis (HSTB) is rare. Only 31 cases have been documented in imaging literature so far. Presented is the clinico-imaging review with five additional new cases of this uncommon variety. Due to nonspecific wide spectrum of imaging appearances, biopsy is mandatory in almost all cases. Clinical recovery and resolution of lesions on imaging may not be directly proportional.