Tuberculosis in Cirrhosis - A Diagnostic and Management Conundrum

Understanding antituberculosis drug-induced hepatotoxicity: Risk factors and effective management strategies in the pediatric population

Antituberculosis drug-induced hepatotoxicity (ATDIH) is a significant concern while managing pediatric tuberculosis. There is limited data on pediatric ATDIH, and much of the management practices are extrapolated from adult experiences. This article provides a comprehensive overview of the incidence, risk factors, clinical presentation, and management strategies for ATDIH in children. Pyrazinamide, isoniazid, and rifampicin are the most hepatotoxic first-line antituberculosis therapy (ATT). Though pyrazinamide has the highest potential for ATDIH, isoniazid is most frequently implicated. Hepatotoxicity typically manifests within the first 2–8 weeks of treatment, particularly during the intensive phase. Risk factors include younger age, female gender, malnutrition, hypoalbuminemia, and baseline liver dysfunction. Extra-pulmonary TB, particularly tuberculous meningitis, and concomitant hepatotoxic medications such as antiretro viral therapy or antiepileptic drugs further increase susceptibility. Genetic predisposition, including N-acetyltransferase 2 and cytochrome P4502E1 polymorphisms and specific HLA alleles also contribute to the increased risk. Clinically, ATDIH ranges from asymptomatic transaminase elevation to severe acute liver failure (ALF), necessitating prompt recognition and intervention. Diagnosis relies on the temporal association of liver injury with ATT initiation, supported by liver function tests, improvement upon ATT cessation, and recurrence upon reintroduction. Management involves discontinuing hepatotoxic drugs, initiating non-hepatotoxic regimens, and sequential reintroduction of ATT under close monitoring. For children with ALF, care in a tertiary center with liver transplantation expertise is essential. While pediatric ATDIH generally has favorable outcomes with timely intervention, delays can result in significant morbidity and mortality. Improved understanding of risk factors, vigilant monitoring protocols, and standardized pediatric management strategies are critical for optimizing outcomes in pediatric ATDIH.

Incidence and risk factors of antituberculosis drug-induced liver injury in India: A systematic review and meta-analysis

BACKGROUND

Antituberculosis drug-induced liver injury (ATDILI) is a significant problem of tuberculosis treatment. This systematic review and meta‑analysis aimed at evaluating the incidence and risk factors of ATDILI in adult patients with tuberculosis in India.

METHODS

Five electronic databases were searched comprehensively for studies on Indian adult patients with tuberculosis investigating the incidence and/or risk factors of ATDILI. The relevant data was pooled in a random or fixed-effect model to calculate the pooled incidence with a 95% confidence interval (CI), standardized mean difference (MD) or odds ratio (OR).

RESULTS

Following the screening of 3221 records, 43 studies with 12,041 tuberculosis patients were finally included. Based on the random effect model, the pooled incidence of ATDILI was 12.6% (95% CI, 9.9-15.3%, p < 0.001, I2 = 95.1%). The pooled incidence was higher in patients with daily treatment regimen compared to the thrice weekly regimen (16.5% vs. 3.5%). The concurrent hepatitis B or C infection, alcohol consumption and underlying chronic liver disease were associated with high incidence of ATDILI. The pooled incidence of acute liver failure (ALF) among ATDILI patients was 6.78% (95% CI 3.9-9.5%). Female gender (OR 1.24), older age (MD 0.26), lean body mass index (OR 3.8), hypoalbuminemia (OR 3.09), N-acetyltransferase slow acetylator genotypes (OR 2.3) and glutathione S-transferases M null mutation (OR 1.6) were found to be associated with an increased risk of ATDILI. The pooled mortality rate of ATDILI patients was 1.72% (95% CI 0.4-3.0%) overall and 71.8% (95% CI 49.3-94.2%) in case of ALF.

CONCLUSION

Overall, 12.6% patients of tuberculosis in India developed ATDILI when combination of first-line antituberculosis drugs was used. An average of 7% of ATDILI patients progressed to ALF which had a high mortality rate. Older age, female, poor nutritional status and some genetic polymorphisms were identified as significant risk factors.

Tuberculosis masquerading as a pancreatic cyst in a patient with cirrhosis

Cystic lesions of the pancreas are being increasingly diagnosed incidentally in recent decades due to easy availability of abdominal imaging. They may be neoplastic or benign. Tuberculosis, the great masquerader, may rarely involve the pancreas mimicking pancreatic malignancy, cyst, or abscess. Identification of this rare entity is crucial to avoid potentially risky surgery as anti-tubercular pharmacotherapy is highly effective. We report a case of a 40-year old cirrhotic man who presented with a cystic hypodense lesion in the pancreatic tail and was subsequently diagnosed with pancreatic tuberculosis. Apart from the rarity of diagnosis, our case also highlights the utility of endoscopic ultrasound for minimally invasive assessment of pancreatic lesions.

Tuberculous pleuritis: clinical presentations and diagnostic challenges

PURPOSE OF REVIEW

Tuberculous pleuritis (TBP) is one of the most common types of extrapulmonary tuberculosis. We highlight the latest epidemiology of TBP, the heterogeneity of its presentation and the performance of different diagnostic strategies.

RECENT FINDINGS

There are differential trends in the incidences of TBP worldwide. Its incidence increased in China but decreased in the United States in the past decade. The presentation of TBP is heterogeneous regarding clinical symptoms, radiological findings and pleural fluid analysis results. Conventional microbiological tests have low sensitivities to diagnose TBP. Recent research focused on various diagnostic tools with better yield. The sensitivity of nucleic acid amplification tests (NAAT) in pleural fluid, including the latest generation of PCR and sequencing-based techniques for detecting tuberculosis, remains suboptimal. Various pleural fluid biomarkers have been explored, but there is a lack of consensus on their clinical utility and cutoff levels.

SUMMARY

The heterogeneity of clinical presentation poses obstacles to diagnosing TBP. Further development of diagnostic tools, including more robust NAAT and biomarkers with additional validation, is needed before incorporation into routine clinical practice.

Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure

Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.

Anti-tuberculosis drug-induced liver injury in patient with hepatitis B and cirrhosis: A case report

Background

Pulmonary tuberculosis patients infected with hepatitis B are at high risk for drug-induced liver injury.

Case presentation

A 42-year-old Indonesian female complained of sclera icterus, tea-colored urine, vomiting, dyspnea, and swollen stomach and legs. The patient experienced this condition after taking anti-tuberculosis drugs for five days. Her medical history showed hepatitis B and cirrhosis. Follow-up examination included chest X-ray and GeneXpert supported a diagnosis of pulmonary tuberculosis. However, abdominal ultrasonography indicated ascites and cirrhosis. We diagnosed the patient with anti-tuberculosis DILI, cirrhosis Child-Pugh C (score 12) related to hepatitis B, and pulmonary tuberculosis. We decided to stop the anti-tuberculosis drug. We treated the patient using tenofovir, hepatoprotective drug, diuretics, and albumin infusion. On the third day, the patient received new anti-tuberculosis drugs, including levofloxacin 750 mg, ethambutol 1000 mg, and streptomycin 1000 mg (LES). The patient's condition then gradually improved.

Discussion

The dilemma of treating tuberculosis in liver disease is treating tuberculosis without ignoring hepatitis B and cirrhosis.

Conclusion

Administration of anti-tuberculosis drugs based on liver tolerance of hepatotoxic drug in patients with hepatitis B and cirrhosis.

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Cirrhosis and Hepatitis B are risk factors for anti-tuberculosis DILI.

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The priority of DILI management is stopping anti-tuberculosis drugs.

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Anti-tuberculosis DILI is treated based on the Child-Pugh category.

Management of Portal Hypertension

Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.

The challenges of ascites management: An Indian perspective

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