Hepatic tuberculosis: a multimodality imaging review

Computed tomography imaging characteristics of paradoxical reactions in perihepatic and hepatic tuberculosis

Background

Hepatic and perihepatic tuberculosis (TB) are rare forms of extrapulmonary TB. Paradoxical reactions, characterized by the enlargement of existing lesions or the appearance of new lesions during anti-TB treatment, are uncommon in hepatic TB. This study aimed to retrospectively analyze the computed tomography (CT) imaging characteristics of paradoxical reactions in hepatic and perihepatic TB to enhance the understanding of this condition.

Methods

We conducted a retrospective review of the data of patients diagnosed with perihepatic and hepatic TB at the Kunming Third People's Hospital from January 2020 to June 2024. We selected patients with follow-up CT imaging showing paradoxical reactions, and we summarized their initial CT findings, paradoxical reaction CT manifestations, and follow-up CT presentations.

Results

The data of 37 patients with perihepatic and hepatic TB and CT follow-up imaging were collected. Of the 37 patients, 14 (37.8%) exhibited paradoxical reactions characterized by an enlargement of existing lesions or the appearance of new lesions on review. Among these 14 patients, 7 were male, 7 were female, with ages ranging from 17 to 46 years (median age: 23 years). Twelve patients had concurrent pulmonary TB, and 13 patients had other extrapulmonary TB. Thirteen patients tested positive for TB infection by interferon-gamma release assay, and eight had positive etiological results. Twelve patients showed a decrease in CD4+ T-cell counts. The time to the paradoxical reaction onset after initial diagnosis ranged from 13 to 183 days (median time: 82 days). The initial CT presentations of these 14 patients included 11 cases of perihepatic peritoneum/hepatic capsule linear or nodular thickening (capsular type), and three cases of combined perihepatic peritoneum/hepatic capsule linear or nodular thickening with hepatic parenchymal lesions (mixed type). Capsular-type paradoxical reactions manifested as new or enlarged nodules of the perihepatic peritoneum/hepatic capsule and intrahepatic lesions, with marked ring enhancement on enhanced scans. Mixed-type paradoxical reactions showed significant enlargement of perihepatic peritoneum/hepatic capsule lesions and intrahepatic lesions, with the enhanced scans showing higher ring enhancement than that in the initial presentation. Among the 12 patients with long-term follow-up data, lesion improvement began at 6 to 20 months (median time: 12 months). CT imaging showed gradual lesion size reduction, decreased ring enhancement density, an absence of ring enhancement, and lesion calcification.

Conclusions

During anti-TB treatment, perihepatic and hepatic TB patients can show paradoxical reactions, which often present as ring enhancement. After treatment, these paradoxical reaction lesions can show improvement. CT-enhanced scans have diagnostic value in the occurrence and progression of perihepatic and hepatic TB.

Development and validation of BCG vaccine-induced novel granulomatous liver injury preclinical animal model

BACKGROUND

Developing a granulomatous liver injury preclinical model may pave the way to understanding hepatic-TB (tuberculosis) and autoimmune granulomatous liver diseases. Antitubercular (ATT) and other drugs' metabolism in the presence of a specific type of liver injury is not well understood. The present study aimed to establish a preclinical model of granulomatous hepatitis by using the BCG (Bacillus Calmette-Guérin) vaccine, further studying it in the presence of ATT dosing, and analyze the pharmacokinetics of isoniazid, rifampicin, and their respective primary metabolites.

METHODS

We used 56 rats in seven equal groups. Group I functioned as a normal control (NC) receiving normal saline only. Groups II-IV received intravenous injections of low-, medium-, and high-dose BCG vaccine daily for 21 days. Groups V, VI, and VII received isoniazid (H) alone, rifampicin (R) alone, and isoniazid + rifampicin(HR) for a subsequent 15 days in addition to high dose BCG for the first 21 days, respectively. Liver function tests (LFT) were monitored on days 0, 21, 28, and 36. Rats were sacrificed later for oxidative stress and histopathological examination.

RESULTS

The study observed BCG dose-specific LFT derangements in groups II-IV compared to group I on day 21 (p < 0.05). Isoniazid, rifampicin, and combination intervention groups demonstrated normalization of the BCG-led LFT changes. Histology and oxidative stress parameters confirmed model development and biochemical changes. Isoniazid area under the curve (AUC) showed a reduction of 16.9% in BCG + HR group in comparison to the BCG + H group (p = 0.01). Des-acetyl-rifampicin AUC and maximum-concentration value demonstrated a significant rise in BCG + HR group in comparison to the BCG + R group (p = 0.001).

CONCLUSION

A novel preclinical model of granulomatous liver injury was developed using the BCG vaccine strain and validated with ATT response.

Tuberculosis Beyond the Lungs: A Pictorial Review of Key Diagnostic Imaging Insights

Tuberculosis (TB) remains a significant global health challenge, traditionally associated with pulmonary manifestations. However, extrapulmonary tuberculosis (EPTB) accounts for a substantial portion of TB cases, particularly in immunocompromised patients. EPTB can affect virtually any organ system and often mimics other infectious, inflammatory, or neoplastic conditions, making diagnosis particularly challenging. This pictorial review aims to illustrate the broad spectrum of imaging findings in EPTB using selected, confirmed cases involving hepatic, splenic, adrenal, pancreatic, genitourinary, lymphatic, gastrointestinal, cardiovascular, musculoskeletal, and central nervous system sites. Magnetic resonance imaging (MRI) and computed tomography (CT) are highlighted for their diagnostic capabilities, with MRI offering superior soft tissue contrast and CT providing high-resolution evaluation of organ involvement and guiding tissue sampling. Each case presented is supported by microbiological, histopathological, or molecular confirmation, reinforcing the importance of correlating radiologic features with definitive diagnostic tools. By enhancing familiarity with the diverse radiologic appearances of EPTB, this review seeks to improve diagnostic confidence and facilitate timely clinical decision-making in complex cases.

Rare Pseudotumoral Hepatic Tuberculosis Mimicking Malignancy: A Diagnostic and Therapeutic Challenge

Pseudotumoral hepatic tuberculosis (TB) is an exceptionally rare manifestation of TB, often mimicking hepatic malignancy on imaging studies. We report the case of a 51-year-old female diagnosed with a low-grade tubulovillous adenoma of the ampulla of Vater, who presented with hepatic lesions initially suspected to be metastatic. Magnetic resonance imaging (MRI) revealed multiple hypointense lesions with heterogeneous enhancement and restricted diffusion. Histopathological examination of a liver biopsy confirmed the diagnosis of pseudotumoral TB. The patient underwent a 6-month course of antitubercular therapy, after which follow-up MRI demonstrated complete resolution of the hepatic lesions. This case highlights the importance of considering pseudotumoral hepatic TB in the differential diagnosis of hepatic masses, particularly in regions with a high prevalence of TB. Histological confirmation remains essential, and timely initiation of antitubercular treatment can result in excellent clinical outcomes.

LEARNING POINTS

This case underscores the importance of including hepatic tuberculosis (TB), particularly its rare pseudotumoral form, in the differential diagnosis of hepatic masses, even in immunocompetent patients without pulmonary involvement or in non-endemic regions.Imaging findings alone may mimic malignancy, emphasizing the critical role of liver biopsy and histopathological analysis in achieving a definitive diagnosis and avoiding unnecessary surgical interventions.Recognizing atypical forms of TB is crucial for timely initiation of antitubercular therapy, which can lead to complete resolution and prevent potentially fatal complications.

Multiloculated thoracoabdominal tuberculosis: A radiological presentation of disseminated tuberculosis

Tuberculosis is more frequently found among high-risk populations in the United States. It has a challenging diagnosis since it can present with diverse organ involvement that may delay the diagnosis. This is especially true regarding hepatic tuberculosis, with prevalence varying in each study but highly suggestive of underdiagnosis. An 18-year-old male with high-risk exposure to multidrug-resistant tuberculosis presented with fever, night sweats, weight loss, and cough. Imaging revealed a right lung cavitary mass with bilateral pulmonary nodules, right pleural nodular thickening traversing diaphragm extending to the liver with subcapsular hepatic lobulated hypodensities. MRI showed spinal involvement consistent with Pott's disease. It is important to consider hepatic tuberculosis in differential diagnoses for a hepatic lesion, allowing early detection and treatment to optimize patient outcomes.

Case report on serohepatic tuberculosis (frosted liver): Clinical presentation, imaging, diagnosis, and management

Hepatic tuberculosis can manifest in various forms, including parenchymal, serohepatic, tuberculous cholangitis and mixed form. Isolated hepatic tuberculosis, specifically in the form of serohepatic tuberculosis, is very rare. Patients with hepatic tuberculosis often present with nonspecific symptoms such as abdominal pain, weight loss, night fever, night sweats, hepatomegaly, and abnormal liver function tests. This case involves a young male with isolated serohepatic tuberculosis who presented to the outpatient department of a tertiary care center with complaints of abdominal discomfort, weight loss, and evening rise in temperature. His liver function tests showed elevated levels of alanine transaminase and aspartate aminotransferase. Ultrasonography of the abdomen revealed multiple subcapsular necrotic lesions in the right lobe of the liver. A contrast-enhanced computed tomography scan of the abdomen showed a few hypodense subcapsular lesions in the right lobe and a minimal subcapsular collection. There was mild thickening and enhancement of the liver capsule and sub capsule, creating a frosted liver or sugar-coated appearance. A small subcentimetric size parenchymal lesion was present in segment VIII, which was in continuity with the subcapsular collection. Fine needle aspiration cytology from the largest subcapsular liver lesion revealed acid-fast bacillus, confirming the tuberculosis diagnosis. A high-resolution CT scan of the chest was performed for further evaluation and showed no abnormalities. The patient is currently being treated with antitubercular therapy.

MRI radiomics model differentiates small hepatic metastases and abscesses in periampullary cancer patients

This multi-center, retrospective study focused on periampullary cancer patients undergoing MRI for hepatic metastasis and abscess differentiation. T1-weighted, T2-weighted, and arterial phase images were utilized to create radiomics models. In the training-set, 112 lesions in 54 patients (median age [IQR, interquartile range], 73 [63-80]; 38 men) were analyzed, and 123 lesions in 55 patients (72 [66-78]; 34 men) comprised the validation set. The T1-weighted + T2-weighted radiomics model showed the highest AUC (0.82, 95% CI 0.75-0.89) in the validation set. Notably, < 30% T1-T2 size discrepancy in MRI findings predicted metastasis (Ps ≤ 0.037), albeit with AUCs of 0.64-0.68 for hepatic metastasis. The radiomics model enhanced radiologists' performance (AUCs, 0.85-0.87 vs. 0.80-0.84) and significantly increased diagnostic confidence (P < 0.001). Although the performance increase lacked statistical significance (P = 0.104-0.281), the radiomics model proved valuable in differentiating small hepatic lesions and enhancing diagnostic confidence. This study highlights the potential of MRI-based radiomics in improving accuracy and confidence in the diagnosis of periampullary cancer-related hepatic lesions.

Peripheral T-cell lymphoma invasion of the liver: The underappreciated hypoechoic periportal cuffing on ultrasound-A case report and literature review

Liver involvement in lymphoma often manifests as nonoccupying diffuse infiltration, posing challenges in distinguishing it from primary liver disorder. Herein, we present the case of a 21-year-old female who underwent two separate diagnoses within a nine-month interval before being ultimately diagnosed with peripheral T-cell lymphoma, not otherwise specified. Our review of this case identified an ultrasound imaging feature, the hypoechoic periportal cuffing. When combined with associated increased lymphocyte count and liver enlargement, it can serve as a noninvasive suggestion for malignant disorders, in particular hemic and lymphatic diseases.

Benign and malignant focal liver lesions displaying rim arterial phase hyperenhancement on CT and MRI

Rim arterial phase hyperenhancement is an imaging feature commonly encountered on contrast-enhanced CT and MRI in focal liver lesions. Rim arterial phase hyperenhancement is a subtype of arterial phase hyperenhancement mainly present at the periphery of lesions on the arterial phase. It is caused by a relative arterialization of the periphery compared with the center of the lesion and needs to be differentiated from other patterns of peripheral enhancement, including the peripheral discontinuous nodular enhancement and the corona enhancement. Rim arterial phase hyperenhancement may be a typical or an atypical imaging presentation of many benign and malignant focal liver lesions, challenging the radiologists during imaging interpretation. Benign focal liver lesions that may show rim arterial phase hyperenhancement may have a vascular, infectious, or inflammatory origin. Malignant focal liver lesions displaying rim arterial phase hyperenhancement may have a vascular, hepatocellular, biliary, lymphoid, or secondary origin. The differences in imaging characteristics on contrast-enhanced CT may be subtle, and a multiparametric approach on MRI may be helpful to narrow the list of differentials. This article aims to review the broad spectrum of focal liver lesions that may show rim arterial phase hyperenhancement, using an approach based on the benign and malignant nature of lesions and their histologic origin. CRITICAL RELEVANCE STATEMENT: Rim arterial phase hyperenhancement may be an imaging feature encountered in benign and malignant focal liver lesions and the diagnostic algorithm approach provided in this educational review may guide toward the final diagnosis. KEY POINTS: Several focal liver lesions may demonstrate rim arterial phase hyperenhancement. Rim arterial phase hyperenhancement may occur in vascular, inflammatory, and neoplastic lesions. Rim arterial phase hyperenhancement may challenge radiologists during image interpretation.

Imaging of infra-thoracic tuberculosis

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

Liver Tuberculosis Presenting As Fever of Unknown Origin: A Case Report and Imaging Spectrum With a Review of Literature

Hepatic tuberculosis is not commonly seen, and it can be easily missed unless there is strong suspicion. It presents clinically with non-specific symptoms like pain in the upper right abdomen, tenderness, mild fever, sweating at night, losing weight, feeling tired, and a lump in the abdomen. We are reporting a case of a 41-year-old female who presented with an intermittent history of fever and right hypochondriac pain for 10 years. Ultrasound and contrast-enhanced computed tomography (CECT) scans of the patient revealed a mass lesion with classical imaging findings of tuberculosis. Subsequently, a biopsy was conducted, confirming the presence of liver tuberculosis.

Tuberculous liver abscess as a unique cause of liver abscess: A case report and literature review

Introduction

TLA is most commonly associated with an immunocompromised state, a focus of infection in the lungs or gastrointestinal system, or as part of congenital or miliary tuberculosis. Isolated TLA is rare, with only a few cases reported in the literature.

Methods

We describe a case of a 24-years-old healthy male with an isolated Tuberculous Liver abscess presented with prolonged fever, abdominal pain, and general malaise. He was successfully treated with a 6-month antituberculosis regimen and percutaneous abscess drainage.

Discussion and conclusion

The signs and symptoms of isolated TLA are nonspecific. The diagnosis requires a high index of suspicion, especially in endemic areas and in individuals with a known tuberculosis risk factor. A better outcome is linked to an early diagnosis and timely treatment with systemic Antituberculous medications. This case report highlights the importance of considering TLA (Tuberculous or Tubercular Liver Abscess) when diagnosing hepatic masses or abscesses as a possible cause of extrapulmonary tuberculosis (EPTB).

Imaging recommendations and algorithms for pediatric tuberculosis: part 2-extrathoracic tuberculosis

Despite advances in diagnosis and treatment in recent years, tuberculosis (TB) remains a global health concern. Children are amongst the most vulnerable groups affected by this disease. Although TB primarily involves the lungs and mediastinal lymph nodes, it can affect virtually any organ system of the body. Along with clinical history combined with physical examination and laboratory tests, various medical imaging tools help establish the diagnosis. Medical imaging tests are also helpful for follow-up during therapy, to assess complications and exclude other underlying pathologies. This article aims to discuss the utility, strengths and limitations of medical imaging tools in the evaluation of suspected extrathoracic TB in the pediatric population. Imaging recommendations for the diagnosis will be presented along with practical and evidence-based imaging algorithms to serve as a guide for both radiologists and clinicians.

Abdominal visceral tuberculosis: a malignancy mimic

The purpose is to discuss abdominal tuberculosis mimicking malignancy involving the abdominal viscera. TB of the abdominal viscera is common, especially in countries where tuberculosis is endemic and in pockets of non-endemic countries. Diagnosis is challenging as clinical presentations are often non-specific. Tissue sampling may be necessary for definitive diagnosis. Awareness of the early and late disease imaging appearances of abdominal tuberculosis involving the viscera that can mimic malignancy can aid detecting TB, providing a differential diagnosis, assessing extent of spread, guiding biopsy, and evaluating response.

Misdiagnosis of Hepatosplenic Schistosomiasis as Hepatic Tuberculosis: A Case Report

We report a case of a 38-year-old woman who was initially misdiagnosed with hepatic tuberculosis and was managed as such before being correctly diagnosed with hepatosplenic schistosomiasis on liver biopsy. The patient had a five-year history of jaundice which over time was accompanied by polyarthritis and then abdominal pain. A diagnosis of hepatic tuberculosis was made clinically and supported by radiographic evidence. She underwent an open cholecystectomy for gallbladder hydrops with the liver biopsy taken revealing chronic hepatic schistosomiasis and was eventually started on praziquantel with good recovery. This case demonstrates a diagnostic issue with the radiographic presentation of the patient and the important role of tissue biopsy in providing definitive care.

Diagnosis of tuberculosis with autoimmune hepatitis–systemic lupus erythematosus overlap syndrome: a case report

Background

There is ample evidence indicating that immunosuppressive therapy or immune dysregulation in systemic lupus erythematosus increases the risk for tuberculosis. Interestingly, a few case reports suggest that tuberculosis could also be a risk factor for systemic lupus erythematosus and other autoimmune diseases.

Case presentation

We report the case of a 32-year-old Indian patient who was co-diagnosed with tuberculosis, systemic lupus erythematosus, and autoimmune hepatitis without any history of prior immunosuppression. This stresses the complex relationship between tuberculosis and autoimmune diseases.

Conclusion

Further research is warranted in this field to unfold the complex relationship between tuberculosis and systemic lupus erythematosus. It is essential to establish clear guidelines for the management of coexisting tuberculosis and systemic lupus erythematosus to promote individualized treatment.

Unusual spread of TB: A case report of hepatic tuberculosis

Tuberculosis (TB) is prevalent in underdeveloped and developing countries, mainly in rural areas, with indistinct clinical manifestations. Lungs are the most affected organs; however, tuberculosis may invade almost all human body systems, including the liver. We provided a case study of a young male adult with hepatic tuberculosis. The diagnosis was established by discovering hypodense nodules with rim enhancement in the liver on CT scan and granulomatous inflammation with caseating necrosis on biopsy. Although having unspecified clinical manifestations, novel liver imaging, combined with pathology examination, is capable of depicting the nature of this entity. Regarding the fact that Mycobacterium tuberculosis culturing may be challenging in most settings, imaging plays a vital role in diagnosing, treatment guiding, and patient follow-ups.

Extrapulmonary tuberculosıs: an old but resurgent problem

Tuberculosis (TB) primarily affects the lungs, but some of its most devastating clinical consequences arise because of its ability to spread from the lungs to other organs. Extrapulmonary TB (EPTB) constitutes 15-20% of all TB cases. Imaging findings are not always specific and can mimic many diseases; therefore, EPTB should be considered in the differential diagnosis, particularly in patients with immune system disorders (AIDS, patients receiving chemotherapy, etc.) and those in other high-risk groups including people with diabetes. The bacterium's passage to the regional lymph nodes is essential for developing a protective T-cell-mediated immune response, but the bacterium can spread hematologically and via the lymphatic system, leading to extrapulmonary involvement. Diagnosis of EPTB in high-risk patients is made based on suspected clinical and radiological findings, but further positive culture and histopathological confirmation may be required in some instances. Radiological evaluations are critical for diagnosis and crucial in planning the treatment and follow-up. This paper aims to review the typical and atypical imaging features and the differential diagnosis of EPTB.

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.

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.

Case Report: Metagenomic Next-Generation Sequencing in Diagnosis of Disseminated Tuberculosis of an Immunocompetent Patient

Disseminated tuberculosis (TB) is a rare disease and mainly occurs in immunodeficient patients. It is marked by hematogenous or lymphatic dissemination of Mycobacterium tuberculosis, causing tuberculous infection involving any organ system. Here, we report a case of disseminated TB involving lung, liver, spine, mediastinum, and prostate in an immunocompetent man. The present patient found a hepatic mass without any symptom during health examination. In the next 2 years, further examinations revealed multiple lesions in the lung, mediastinum, spine, and prostate. Imaging examinations, such as contrast-enhanced abdominal CT, F-18 FDG-PET/CT, and radionuclide bone scan, suggested the diagnosis of malignancy or metastatic tumor. Furthermore, histopathological results of the biopsies of the hepatic mass, mediastinal mass, and prostatic mass demonstrated granulomatous inflammation. Therefore, metagenomic next-generation sequencing (mNGS) was utilized to confirm the diagnosis. Mycobacterium tuberculosis complex was simultaneously detected in the spinal surgical resection specimens and bronchoalveolar lavage fluid (BALF), indicating the diagnosis of disseminated TB. mNGS is an emerging molecular diagnostic technology, and its application in disseminated TB has been rarely reported. We highlight that disseminated TB should be considered even in an immunocompetent patient, and mNGS can be performed when the diagnosis is difficult.

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.

Pyogenic Liver Abscess Risk in Patients With Newly Diagnosed Type 2 Diabetes Mellitus: A Nationwide, Population-Based Cohort Study

Background: To date, no comprehensive epidemiological study exists on pyogenic liver abscess (PLA) risk in patients with newly diagnosed type 2 diabetes mellitus (T2DM) worldwide. Methods: We conducted a retrospective cohort study by using data from Taiwan National Health Insurance Research Database (NHIRD) to examine the association between newly diagnosed T2DM and PLA. The T2DM cohort included patients newly diagnosed as having T2DM (ICD-9-CM:250) from 2000 to 2009, with follow-up until December 31, 2011. The comparison cohort was then recruited through 1:4 random frequency matching with the T2DM cohort. Finally, the adjusted hazard ratios for PLA were compared between the T2DM and comparison cohorts, which included 44,728 patients with T2DM and 178,912 patients without DM respectively. Results: In T2DM cohort, 166 patients were diagnosed as having PLA (incidence rate = 5.87 per 10,000 person-years) and in comparison cohort, 238 patients were diagnosed as having PLA (incidence rate = 2.06 per 10,000 person-years). The T2DM cohort exhibited higher PLA risk than did the comparison cohort (hazard ratio = 2.83, 95% confidence interval = 2.32-3.46). Furthermore, the adjusted hazard ratio for PLA risk in T2DM cohort was the highest in those who were younger, man and with duration of DM <2 years. In the T2DM cohort, the most common PLA causative agent was Klebsiella pneumonia (KP). In addition, PLA risk was high in T2DM patients with gallstone and cholecystitis. Compared with comparison cohort, patients with T2DM prescribed acarbose has a lower PLA risk, however glyburide significantly increased PLA risk in T2DM cohort. Conclusion: In patients with newly diagnosed T2DM, PLA risk was high and acarbose might reduce PLA risk.

Ileocecal and hepatic tuberculosis mimicking a metastatic cecal malignancy: Case report

We wish to highlight that on encountering a suspicious hepatic and a colonic lesion, the possibility of TB should also be kept in mind apart from the obvious possibility of metastasis of a colonic cancer especially in an endemic country like Tunisia.

Liver segmentectomy surgery for delayed diagnosed hepatic TB, a case report from Syria

Introduction and importance: Mycobacterium Tuberculosis infection is still one of the most common causes of morbidity and mortality worldwide. TB usually infects the lungs, but it can affect other organs. Hepatic involvement usually occurs with disseminated disease whereas isolated hepatic involvement is extremely rare. Case presentation: We present a case of a female patient who had to undergo major hepatic surgery due to delayed diagnosis of hepatic TB. It suffered from recurrent abdominal abscesses and general symptoms for a period of time. clinical Discussion: Medical therapy is the treatment of choice and surgery is justified only in specific cases. Surgical intervention may range from less complicated procedures as local excision, abscess drainage or biliary drainage to more complicated and major surgeries such as liver segmentectomy and hemihepatectomy. conclusion: Although rare, physicians should suspect and diagnose early, to give the patient the best chance to benefit from medical therapy and avoid the need for surgical intervention.

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Although rare, hepatic TB still occurs with no specific symptoms or imaging study making it challenging.

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Surgical intervention may range from less complicated procedures to more complicated and major surgeries.

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The delayed decision to refer to a tertiary hospital for other options of treatment made her quality of life poor.

TB or not TB: A comprehensive review of imaging manifestations of abdominal tuberculosis and its mimics

The ever-growing prevalence of tuberculosis is a cause for concern among both developing and developed countries. Abdominal tuberculosis is the most common site of extrapulmonary tuberculosis and involves almost all of the visceral organs. Clinical presentation of abdominal tuberculosis is often non-specific. Thus, having a high index of clinical suspicion is necessary to aide early diagnosis and guide prompt initiation of appropriate treatment. In this review, we focus on the entire spectrum of abdominal tuberculosis and other diseases mimicking it with an emphasis on their imaging findings.

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.

Other types of diffuse liver disease: is there a way to do it?

There are a variety of less common diffuse liver diseases that can be asymptomatic or cause severe liver dysfunction. For the majority of them, the association of clinical, laboratory, and imaging findings are needed to narrow the differential diagnosis. In this article, we will review and describe the rarer diffuse liver diseases including drug-related liver disease, inflammatory and infectious diseases, and deposition disorders such as amyloidosis, glycogen storage disease, Wilson's disease, and alpha-1 antitrypsin deficiency. Abdominal radiologists should be familiar with the imaging features of different types of diffuse liver diseases to help the multidisciplinary team involved in the treatment of these patients. The data related to some of these conditions are scarce and sometimes experimental, but we want to demonstrate to the reader the value of imaging techniques in their analysis and introduce the potential of new imaging methods.

Hepatic tuberculosis masquerading as cholangiocarcinoma: an unusual differential for a liver mass

A 54-year-old woman presented with an incidentally identified asymptomatic liver lesion with imaging characteristics suspicious for malignancy. She underwent a left hemihepatectomy for presumed cholangiocarcinoma. Histopathology revealed granulomas with microbiological investigations later revealing a diagnosis of isolated hepatic tuberculosis. There were no pulmonary or other disease sites identified. The patient has been medically managed for primary hepatic tuberculosis and remains well postoperatively. This case identifies a rare differential for a liver mass that needs to be considered in the clinicians’ workup.

Non-neoplastic hepatopancreatobiliary lesions simulating malignancy: can we differentiate?

Despite the success of cross-sectional imaging in evaluating hepatopancreatobiliary system malignancies, several non-malignant disease processes may closely mimic malignancy. Differentiating these benign diseases from malignancy may be difficult, or even impossible, even in the hands of experienced imagers. In this manuscript, we present benign mimics involving the hepatopancreatobiliary system and try to increase awareness of these potential pitfalls.

A Retrospective Case-Control Study to Evaluate the Diagnostic Accuracy of Honeycomb Sign in Melioid Liver Abscess

Among pyogenic liver abscesses, melioid etiology is considered in endemic regions in the presence of known health or occupational risk factors. "Honeycomb sign," used to describe an abscess with multiple internal septations dividing the abscess cavity into multiple loculations of comparable sizes on imaging, is a sensitive sign for melioid liver abscess. This is a retrospective case-control study investigating incidence, sensitivity, and specificity of "honeycomb sign" in melioid liver abscess, in a cohort of patients with culture-proven melioidosis infection. Abscesses ≥ 2 cm were analyzed for the honeycomb sign. P value < 0.05 was taken as statistically significant. Interobserver agreement was calculated between two radiologists for the presence of the sign, sensitivity, and specificity. A total of 40 abscesses were analyzed. Thirty-four abscesses (85%) manifested the honeycomb sign with interobserver agreement (kappa = 0.70 and 0.92). Sensitivity of the sign is 85% (95% confidence interval [CI]: 70-94%), specificity is 75% (95% CI: 59-87%), positive predictive value is 77% (95% CI: 62-88%), and negative predictive value is 83% (95% CI: 67-94%). If abscess size is ≥ 3 cm, the sensitivity is 91% (95% CI: 77-98%), specificity is 75% (95% CI: 59-87%), positive predictive value is 76% (95% CI: 61-88%), and negative predictive value is 91% (95% CI: 76-98%). Honeycomb sign is a novel imaging marker for melioid liver abscess. Increased awareness and recognition of this imaging feature has the potential to affect patient management.

Hepatic nontuberculous mycobacterial granulomas in patients with cancer mimicking metastases: an analysis of three cases

Hepatic granulomas caused by nontuberculous mycobacteria (NTM) are an uncommon, insidious, and indolent disease. Making an accurate diagnosis of a hepatic nontuberculous granuloma is challenging because of nonspecific clinical presentations and radiological appearances, especially in patients with a history of malignant tumors, as these lesions may mimic metastases and make a dilemma for decision-making in treatment. Herein, we report three cases of hepatic nontuberculous granulomas following operations for malignant tumors, including colon cancer, ovarian adenocarcinoma, and both rectal and renal carcinoma, respectively. Two patients presented with multiple hepatic lesions and the third had a solitary nodule in the liver. Computed tomography (CT) showed low attenuating nodules without early enhancement in the arterial phase but a slight peripheral enhancement in the portal venous phase after the intravenous administration of contrast agent. Magnetic resonance imaging (MRI) showed high signal intensity on T2-weighted image, rim enhancement in the venous phase and no contrast agent of Gd-EOB-DTPA uptake in the hepatobiliary phase. The biopsy was performed, and histopathological examinations revealed the chronic granulomas composed of epithelioid histiocytes, inflammatory cells, and Langhans giant cells. The results of nested polymerase chain reaction (PCR) were positive for NTM.

Differentiation of hepatic abscess from metastasis on contrast-enhanced dynamic computed tomography in patients with a history of extrahepatic malignancy: emphasis on dynamic change of arterial rim enhancement

OBJECTIVES

The objective of the study is to identify computed tomography (CT) findings that differentiate hepatic abscess from hepatic metastasis in a patient with a history of extrahepatic malignancy.

MATERIALS AND METHODS

This retrospective study included 30 patients with 93 hepatic abscesses and 40 patients with 125 hepatic metastases who had a history of extrahepatic malignancy and underwent contrast-enhanced dynamic CT with arterial phase (AP) and portal venous phase (PVP). The diagnosis of hepatic abscess and hepatic metastasis was made using pathological confirmation or clinical diagnosis. Margin, patchy parenchymal enhancement, arterial rim enhancement, dynamic change of arterial rim enhancement, size discrepancy of lesions between arterial and portal phases, bile duct dilatation, perilesional hyperemia, and perilesional low density were evaluated by two radiologists independently. Significant findings for differentiating two groups were identified at univariate and multivariate analysis with nomogram for predicting hepatic abscess. Interobserver agreement was also analyzed for each variable.

RESULTS

Multivariate analysis revealed that patchy parenchymal enhancement (P < 0.001), arterial rim enhancement persistent through PVP (P < 0.001), and perilesional hyperemia (P = 0.013) were independent significant findings to predict hepatic abscess than metastasis. Among them, arterial rim enhancement persistent through PVP showed a highest odds ratio (OR 33.73) on multivariate analysis and a highest predictor point on a nomogram for predicting hepatic abscess. When two of these three criteria were combined, 80.7% (75/93) of hepatic abscess were correctly identified, with a specificity of 85.6% (107/125). When all three criteria were satisfied, specificity was up to 100% (125/125).

CONCLUSIONS

At contrast-enhanced dynamic CT, patchy parenchymal enhancement, arterial rim enhancement persistent through PVP, perilesional hyperemia, and their combinations may be reliable CT features for differentiating hepatic abscess from metastasis in patients with a history of primary extrahepatic malignancy.

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.

Tuberculosis (TB) of the Porta Hepatis Presenting with Obstructive Jaundice Mimicking a Malignant Biliary Tumor: A Case Report and Review of the Literature

Localized hepatobiliary tuberculosis (TB) is a rare disorder which can present with an obstructive jaundice mimicking other noninfectious causes such as cholangiocarcinoma. Here, we report a case of porta hepatis tuberculosis in 19-year-old female who presented with an obstructive jaundice, and her computed tomography (CT) of the abdomen revealed a hepatic hilar mass with radiological features mimicking a malignant biliary tumor. We also review the literature related to this disorder.

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.

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.

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.

Hepatosplenic tuberculosis simulating secondary malignant lesions with cholangitis

Background

Hepatic and/or splenic tuberculosis may simulate much pathology including malignancies, which can roam the diagnosis. Biopsy is necessary for diagnosis. The treatment allows healing and a cleaning of radiological lesions.

Case presentation

We report a case of a 48-old-black Senegalese woman, immunocompetent, hospitalized for febrile jaundice and poor general condition. Imaging and hepatic biopsy showed hepatosplenic tuberculosis with cholangitis, simulating secondary malignancies lesions. The outcome was favorable under treatment.

Conclusion

In front of hepatic nodular lesions simulating malignancies in a tuberculosis endemic areas, achieving a liver biopsy helps rectify the diagnosis.