Hepatic and Intra-abdominal Tuberculosis: 2016 Update

A Case of Hepatic Tuberculosis in a Patient on Adalimumab for Ankylosing Spondylitis

Hepatic tuberculosis (TB) is an uncommon extrapulmonary manifestation of tuberculosis. Hepatic TB is more common in immunocompromised patients, such as those on immunosuppressive medications or those with a human immunodeficiency virus (HIV) infection. Primary hepatic TB is rare, and liver involvement is often secondary to spreading from the lymphatics, portal vein, or hepatic artery. We report a case of hepatic TB in a patient on adalimumab for ankylosing spondylitis (AS).

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.

Acute Promyelocytic Leukemia Treatment Masking Hepatic Tuberculosis: A Management Dilemma

Acute promyelocytic leukemia is a form of acute myeloid leukemia (AML) that is characterized by presence of a promyelocytic leukemia-retinoic acid receptor alpha fusion. In most patients, this fusion is detected on conventional karyotype as the t(15;17)(q24.1;q21.2) translocation, but some patients have cryptic translocations with a normal karyotype. Historically, AML is associated with a poor prognosis. Treatment with all-trans retinoic acid and arsenic trioxide assures long-term survival in the majority of patients. This treatment is generally well-tolerated but may cause hepatotoxicity. This is usually identified by transaminitis but resolves after temporary cessation of treatment. Our patient's hepatotoxicity did not resolve following all-trans retinoic acid and arsenic trioxide cessation which posed a diagnostic dilemma. This prompted exploration of other possible causes of hepatotoxicity. An eventual liver biopsy identified acid-fast bacilli, confirming a diagnosis of hepatic tuberculosis. A broad differential diagnosis is imperative when investigating abnormalities in liver function, especially in chemotherapy patients when treatment cessation may cause cancer progression.

Mimics of Crohn's Disease

Crohn's disease is a chronic inflammatory disease that can affect any portion of the gastrointestinal tract. Associated symptoms can vary based on the severity of disease, extent of involvement, presence of extraintestinal manifestations, and development of complications. Diagnosis is based on a constellation of findings. Many diseases can mimic Crohn's disease and lead to diagnostic conundrums. These include entities associated with the gastrointestinal luminal tract, vascular disease, autoimmune processes, various infections, malignancies and complications, drug- or treatment-induced conditions, and genetic diseases. Careful consideration of possible causes is necessary to establish the correct diagnosis.

Clinical, laboratory and evolutionary features of abdominal tuberculosis in comparison with other forms of extrapulmonary tuberculosis

BACKGROUND/OBJECTIVES

Tuberculosis is a multisystem disease that might affect any organ. Abdominal tuberculosis (ABT) represents 5-17% from all extrapulmonary tuberculosis (EPT) sites. We aimed to study the clinical, laboratory and evolutionary features of ABT cases and to identify predictive factors associated with ABT.

METHODS

We conducted a retrospective study including all patients hospitalized in the infectious diseases department for EPT between 1991 and 2019. We studied the characteristics of ABT cases, and we compared them with other EPT cases.

RESULTS

We identified 519 patients with EPT, among whom 86 (16.6%) patients had ABT. There were 58 females (67.4%). Peritoneal tuberculosis was the most common clinical form of ABT (68.6%), followed by intestinal tuberculosis (18.6%). Patients aged 60 years and above were significantly less affected with ABT (odds ratio (OR) = 0.2; p = 0.001). The revealing systemic symptoms including fever (OR = 2.04; p = 0.006), weight loss (OR = 2.5; p < 0.001) and anorexia (OR = 1.7; p = 0.021) were significantly more frequent among ABT patients. Inflammatory markers including C-reactive protein levels (37 [10-89] mg/l vs 10 [4-57] mg/l; p < 0.001) and erythrocyte sedimentation rates (43 [15-95] mm/h vs 27 [15-60] mm/h; p = 0.044) were significantly higher among ABT cases. Multivariate logistic regression analysis showed that anorexia (adjusted OR (AOR) = 1.9; p = 0.015) and pulmonary involvement (AOR = 3.3; p = 0.002) were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal (AOR = 0.18; p = 0.001) and osteo-articular (AOR = 0.2; p = 0.01) sites, 40-59 (AOR = 0.2; p < 0.001) and ≥60 (AOR = 0.2; p < 0.001) age groups as well as hemoglobin rate (AOR = 0.7; p < 0.001) were independently associated with lower rate of ABT.

CONCLUSIONS

Anorexia and pulmonary involvement were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal and osteo-articular sites, 40-59 and ≥60 age groups and hemoglobin rate were independently associated with lower rate of ABT.

Esophageal tuberculosis induced dysphagia: a case report

Background

Patients can present for a wide variety of etiologies for dysphagia, and it is important to consider less common causes once common etiologies have been ruled out. Extrapulmonary Mycobacterium tuberculosis (TB) presentations are rare to see in the western populations due to relative lack of TB exposure and overall less immunocompromised populations, but should be considered for at-risk patients. Gastrointestinal (GI) TB is rare, and the GI tract is considered only the sixth most frequent site of extrapulmonary TB (EPTB).

Case presentation

This is a case report of a 35-year-old Ethiopian male presenting with dysphagia and retrosternal odynophagia who was found to have infiltration of mediastinal lymphadenopathy into the esophageal wall secondary to TB. This patient underwent an upper endoscopy, which revealed a linear 2 cm full thickness mucosal defect in the middle esophagus concerning for an infiltrative process with full thickness tear. Computed tomography (CT) of the chest demonstrated a subcarinal soft tissue mass that was inseparable from the esophagus. He was referred to thoracic surgery and underwent an exploratory mediastinal dissection. A mediastinoscopy scope was inserted and the mediastinal dissection was made until the subcarinal nodes were identified and removed. Biopsy results showed necrotizing and non-necrotizing granulomas, and acid-fast bacilli (AFB) culture from the surgically removed lymph node showed Mycobacterium TB complex growth. He had no known TB exposures and did not have any TB risk factors. He then followed up in infectious disease clinic and was managed with anti-tuberculosis treatment (ATT) with complete resolution of symptoms.

Conclusions

Our patient was ultimately found to have esophageal TB secondary to mediastinal invasion into the esophageal wall from lymphadenopathy associated with TB. This is an extremely rare presentation in western populations due to diminished exposure rates and overall less immunocompromised populations compared to impoverished countries with increased TB exposure and human immunodeficiency virus (HIV) infection rates. Although TB is not as commonly seen in western populations, it should be considered on the differential for any atypical presentations of GI diseases for patients with clinical or geographic risk factors.

Misidentification of hepatic tuberculosis as cholangiocarcinoma: A case report

BACKGROUND

Hepatic tuberculosis (TB) is uncommon clinically. Because of a lack of specific signs, characteristic symptoms and clinical manifestations and because pathological samples are difficult to obtain, hepatic TB is easily missed or misdiagnosed.

CASE SUMMARY

A 62-year-old Chinese man presented with jaundice for 1 wk and no abnormal laboratory tests other than elevated bilirubin, aminotransferases and C-reactive protein. Computed tomography (CT) of the abdomen showed a mass in the left lobe of the liver and hepatic hilum with striped calcified foci. Mild enhancement was visible at the edges, along with extensive intrahepatic biliary ductal dilatation in the right lobe of the liver. In the arterial phase of both CT and magnetic resonance imaging, the main trunk and right branch of the portal artery were partially visualized. Magnetic resonance cholangiopancreatography (MRCP) indicated that the left lobe of the liver and most of the bile ducts in the hilum were not visible. Pathological examination revealed coagulative necrosis, and granulomatous nodules were seen around areas of necrosis; therefore, TB was considered.

CONCLUSION

Hepatic tuberculosis is easily misdiagnosed or missed on imaging. Percutaneous puncture biopsy is the most useful tool for definitive diagnosis.

A 55-Year-Old Japanese Man with Multiple Sclerosis Diagnosed with Disseminated Tuberculosis Identified by Liver Function Abnormalities: A Case Report

Patient: Male, 55-year-old

Final Diagnosis: Tuberculosis

Symptoms: Liver

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

Abdominopelvic Mass Revealing Tuberculosis in a Young Woman

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis and remains a health problem, especially in developing countries. Abdominal location represents 5 to 10% of all locations. The clinical symptoms are not very specific, and the discovery of an abdominal mass in a context of deterioration of general state may wrongly lead to the diagnosis of a tumor. Radiological explorations remain sensitive in the detection of abdominal masses but they cannot prejudge their etiology. Surgical exploration is sometimes the only recourse either for diagnostic purposes or complications, and the diagnosis can only be confirmed by bacteriological and histological examinations of the surgical specimen. We report the case of abdominopelvic mass and lymph nodes revealing tuberculosis.

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.

Intestinal Tuberculosis: A Diagnostic Challenge

Diagnosing intestinal tuberculosis (TB) with uncommon clinical manifestations is often challenging. Here, we report a case of an alcoholic patient who presented with vague symptoms and was later diagnosed with intestinal TB. This patient experienced multiorgan failure causing hemodynamic instability requiring ionotropic support; acute hypoxic respiratory failure managed with non-invasive positive pressure ventilation, hepatic failure, transudative peritoneal effusion, and transudative pleural effusion. These conditions clouded our judgment to pursue colonoscopy for a definite diagnosis and delayed the anti-tuberculosis treatment. When intestinal tuberculosis TB is suspected, the differential diagnosis must be established with other gastrointestinal involving diseases, including mycobacterium avium complex (MAC) and Crohn's disease (CD). MAC can show overlapping features with intestinal TB or coexist with it; Acid-fast stain and tissue culture are the key tests to differentiate these two. In the presence of diagnostic uncertainty between intestinal TB and CD, a therapeutic trial with anti-tuberculous therapy may be warranted.

Thinking Outside the Lungs: A Case of Disseminated Abdominal Tuberculosis

Patient: Female, 47-year-old

Final Diagnosis: Intraperitoneal tuberculosis

Symptoms: Abdominal pain • decreased appetite

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases • Medicine, General and Internal

Case report demonstrating abdominal tuberculosis presenting as an irreducible para-umbilical hernia

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Diagnosis of abdominal tuberculosis is challenging due to non-specific findings and clinical signs.

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A high index of suspicion of abdominal tuberculosis should be kept especially in endemic areas and for immune compromised patients who present with non-specific abdominal symptoms.

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Abdominal tuberculosis rarely presents as umbilical hernias with only 1 reported case in the literature.

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Routine histopathologic examination of hernial sacs should be considered in high endemic areas of abdominal tuberculosis.

Introduction

Abdominal tuberculosis is a common form of extrapulmonary tuberculosis. Clinical manifestations and presentations are diverse depending on the organ involved within the abdominal cavity.

Presentation of case

26-year-old female with a background history of human immunodeficiency virus (HIV) presented with multiple irreducible para-umbilical hernias as the primary presentation of abdominal tuberculosis. Emergency hernia repair surgery revealed features of abdominal TB that was confirmed on polymerase chain reaction and histopathology. The patient was initiated on anti-tuberculosis therapy and was in a stable condition upon discharge.

Discussion

The uncommon presentation described is very rare with only one documented case of abdominal tuberculosis diagnosis with an umbilical hernia. Abdominal tuberculosis can present with a wide range of symptoms with a variety of imaging and invasive modalities available to confirm the diagnosis.

Conclusion

This case report is the second documented case of abdominal tuberculosis within a paraumbilical hernia. The case report highlights paucity within literature related to the histopathological diagnosis of hernial sacs within an endemic area of tuberculosis. Further research within hernia registries of the histopathological diagnosis of hernia sacs will be beneficial for surgeons in endemic areas of abdominal tuberculosis.

Left-sided portal hypertension caused by peripancreatic lymph node tuberculosis misdiagnosed as pancreatic cancer: a case report and literature review

Background

Left-sided portal hypertension (LSPH) is an extremely rare clinical syndrome, and it is the only form of curable portal hypertension. It is primarily caused by pancreatic disease, and is associated with complications that cause spleen vein compression. Specific symptoms are often lacking, rendering it difficult to diagnose. Splenectomy is the main treatment for cases complicated by variceal bleeding, and the effects of treatment primarily depend on the condition of the primary disease.

Case presentation

The patient was a 29-year-old woman who was admitted to the hospital for repeated hematemesis and black stool. She had been misdiagnosed with pancreatic cancer 7 years prior. Combined imaging and endoscopic examination indicated varicose gastric fundus veins, a pancreatic mass, and enlarged peripancreatic lymph nodes. Laboratory investigations revealed reduced erythrocyte, platelet, and leukocyte counts, the interferon gamma release assay was positive, and liver function was normal. Abdominal exploration, splenectomy, varicose vein dissection, and lesion resection were performed via laparotomy. Postoperative biopsy analysis confirmed the diagnosis of lymph node tuberculosis. Based on the above-described factors, LSPH caused by peripancreatic lymph node tuberculosis was a diagnosed.

Conclusions

Herein we describe the first reported case of LSPH caused by peripancreatic lymph node tuberculosis. When left portal hypertension occurs simultaneously, peripancreatic lymph node tuberculosis is often misdiagnosed as pancreatic cancer. Further studies are necessary to develop a more favorable diagnostic method for pancreas masses and more advantageous therapy for LSPH, especially in cases caused by mechanical compression.

Hepatitis in children with tuberculosis: a case report and review of the literature

Background

Hepatitis in young children with tuberculosis (TB) outside miliary TB is not well described and represents a challenge because of the hepatotoxicity associated with first-line anti-TB treatment.

Case presentation

We report an antibiotic naïve 13-month-old male from Nepal with pulmonary TB and hepatitis, who improved after TB treatment. We also performed a literature review for TB-associated hepatitis in children.

Conclusions

Liver function tests should be considered, when feasible, in infants and young children with pulmonary TB. Testing could help to identify and manage patients with TB-associated hepatic abnormalities, and also to establish a baseline for detection and management of liver injury associated with anti-TB therapy.

Tuberculosis and the Acute Abdomen: An Evaluation of the National Inpatient Sample

Background: Tuberculosis can cause acute abdominal pathology requiring operation. While most cases of tuberculosis resolve with appropriate anti-mycobacterial therapy, a surgical procedure still may be required. We sought to describe the modern epidemiology of acute abdominal pathology associated with tuberculosis in the United States. Methods: We retrospectively analyzed the 2010-2014 National Inpatient Sample for admissions associated with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for both tuberculosis and acute abdominal pain. Cases of acute abdominal tuberculosis were defined as inpatient admissions with a diagnosis of tuberculosis and a diagnosis of acute abdominal pain. Outcomes of interest included need for abdominal operation and death after operation. Adjusted analyses accounting for survey methodology were performed. Results: There were 66,034 inpatient admissions associated with tuberculosis of which 3638 (6%) included a diagnosis of acute abdominal pain. Among cases, 1578 (43%) were 45-64 years old and 2344 (64%) were male. Most patients were Hispanic (n = 1090, 30%) or black (n = 924, 25%) and were in the lowest quartile of income by zip code (n = 1367, 38%). A total of 347 (0.5% of total) patients underwent an operation. Procedures included peritoneal biopsy (n = 136, 39%), repair or resection of a hollow viscus (n = 122, 35%), and abdominal exploration (n = 111, 32%). In adjusted analysis, undergoing a surgical procedure was found to depend on the type of tuberculosis infection (odds ratio [OR] = 1.17 for intestinal, peritoneal, or genitourinary tuberculosis versus other types, 95% confidence interval [CI] = [1.12-1.22]) and whether the patient was white or Asian race versus black and Hispanic (OR = 1.11, 95% CI [1.02-1.21]). Thirty-nine (11%) of the 347 patients who underwent a surgical procedure died during hospitalization. Conclusions: An operation still may be required for patients with tuberculosis presenting with acute abdominal pain. Black and Hispanic patients are less likely to receive surgical intervention than whites or Asians. The inhospital deaths from acute abdominal pain necessitating operation among patients with tuberculosis are high.

Diagnosis of abdominal tuberculosis: lessons learned over 30 years: pectoral assay

Diagnosing abdominal tuberculosis remains a great challenge even for experienced clinicians. It is a great mimicker that has unusual presentations. A high index of suspicion is essential for reaching its diagnosis. Clinical and radiological findings of abdominal tuberculosis are non-specific. Herein, we report the lessons we have learned over the last 30 years stemming from our own mistakes in diagnosing abdominal tuberculosis supported by illustrative challenging clinical cases. Furthermore, we report our diagnostic algorithm for abdominal tuberculosis. This diagnostic algorithm will help in reaching the proper diagnosis by histopathology or microbiology. Our diagnostic workup depends on categorizing the clinical and radiological findings of abdominal tuberculosis into five different categories including (1) gastrointestinal, (2) solid organ lesions, (3) lymphadenopathy, (4) wet peritonitis, and (5) dry/fixed peritonitis. The diagnosis in gastrointestinal tuberculosis and dry peritonitis can be reached by endoscopy. The diagnosis in solid organ lesions can be reached by ultrasound-guided aspiration. The diagnosis in wet peritonitis and lymphadenopathy can be reached by ultrasound-guided aspiration followed by laparoscopy if needed. Diagnostic laparotomy should be kept as the last option for achieving a histological diagnosis. Capsule endoscopy and enteroscopy were not included in the diagnostic algorithm because of the limited data of using these modalities in abdominal tuberculosis. They need special expertise, and rarely used in low- and middle-income countries. Furthermore, capsule endoscopy may cause complete intestinal obstruction in small bowel strictures. A definite diagnosis can be reached in only 80% of the patients. Therapeutic diagnosis should be tried in the remaining 20%.

Intra-abdominal lymphatic tuberculosis as a rare case of small intestine volvulus

Tuberculosis used to be uncommon in the developed countries but seems to be still on rampant in developing countries. However, there seems to be an increasing occurrence in the developed countries too mainly due to low living conditions, increased migration, HIV immune-compromisation and inappropriate use of antitubercular drugs. Lymphatic tuberculosis is the second commonest extrapulmonary location of tuberculosis followed by genitourinary, bone and joint, miliary, meningeal and abdominal. Abdominal tuberculosis represents nearly 11%–16% of all extrapulmonary tuberculosis locations. Furthermore, abdominal tuberculosis co-exists with pulmonary tuberculosis in 10%–30% of patients. Abdominal tuberculosis remains difficult to diagnose due to non-specific symptoms, variable anatomical locations and lack of specific sensitive diagnostic tools. Diagnosis can be rarely suspected, especially in cases of isolated abdominal tuberculosis without clinical or radiological findings. We present a rare case of a patient with pulmonary tuberculosis combined with intra-abdominal lymphatic tuberculosis causing small intestine volvulus.

Hepatic hilar mass in an adolescent: a rare case of hepatobiliary tuberculosis

Background

Hepatobiliary tuberculosis is a rare manifestation of Mycobacterium tuberculosis infection, especially in younger patients. The non-specific symptoms and signs as well as the lack of definite imaging characteristics often impedes diagnosis. Definite diagnosis of tuberculosiscan be obtained through histopathological examination; conventional anti-tuberculosis drugs and surgery are the most commonly recommended treatments.

Case presentation

A previously healthy 15-year-old rural adolescent male presented with a 2-month history of weight loss and fatigue. We strongly suspected a Klatskin tumor; therefore, exploratory laparotomy was performed. However, the microscopical findings revealed a granuloma consisting of epithelioid cells, caseous necrosis, and lymphocytic infiltration, indicating caseating granulomatous inflammation and yielding a final diagnosis of hepatic hilar tuberculosis.

Conclusion

Hepatic hilar tuberculosis is an extremely rare case; few physicians may have actually treated a case. This report therefore aims to improve the overall understanding of lymphatic tuberculosis of the hepatic hilum.

Point-of-Care Ultrasound for Extrapulmonary Tuberculosis in India: A Prospective Cohort Study in HIV-Positive and HIV-Negative Presumptive Tuberculosis Patients

Diagnosing extrapulmonary tuberculosis (EPTB) is challenging. Point-of-care ultrasound (POCUS) for human immunodeficiency virus (HIV)-associated EPTB is applied in sub-Saharan Africa. This study aimed at evaluating the applicability of POCUS for diagnosing EPTB in HIV-positive and HIV-negative presumptive tuberculosis (TB) patients in India, a country of moderate relative TB and HIV burden. Presumptive TB patients at Kasturba Hospital, Manipal, India, prospectively underwent POCUS evaluating for pericardial, pleural and ascitic effusion, abdominal lymphadenopathy, and hepatic and splenic microabscesses. Findings were correlated with TB category (confirmed TB, clinical TB, unlikely TB), HIV status, and discharge diagnoses. A total of 425 patients underwent POCUS; 81 (20%) were HIV-positive. POCUS findings were more common in HIV/TB coinfected patients than in HIV-positive patients with unlikely TB (24/40 (60%) versus 9/41 (22%), P < 0.001). Abdominal lymphadenopathy and splenic microabscesses were strongly associated with TB in HIV-positive patients (P = 0.002 and P = 0.001). POCUS findings did not correlate with TB in HIV-negative patients; a third of HIV-negative patients with unlikely TB and POCUS findings had cancer, another third other infectious diseases. Sonographic findings were common in HIV-positive and HIV-negative presumptive TB patients. POCUS was a useful bedside test for the detection of HIV-associated EPTB. In HIV-negative patients, POCUS detected features associated with EPTB but also of malignancy and other infectious diseases.

Tuberculous peritonitis in children: Two case reports highlighting the important role of imaging

Tuberculous peritonitis is an uncommon extrapulmonary form of Mycobacterium tuberculosis infection, frequently presenting with nonspecific and insidious symptoms. Diagnosis is therefore difficult, unsuspected, and often delayed, especially in the pediatric patient without an obvious history of exposure to the pathogen.

This report presents a 9-year-old Hispanic girl and a 3-year-old African American boy presenting with nonspecific and insidious symptoms, such as abdominal pain, distention, and fever in whom computed tomography findings of peritoneal thickening and enhancement, high density ascites, lymphadenopathy, and bowel wall thickening acted as key components in establishing a final diagnosis of the condition. Computed tomography is an important clinical adjuvant in making this difficult diagnosis.