Hepatic granulomas: a 10 year single centre experience

Visceral leishmaniasis as a rare cause of granulomatous hepatitis

Visceral leishmaniasis (VL) is a potentially fatal infection caused by species of Leishmania. It is characterized by fever, weight loss, anemia, and enlargement of the spleen and liver. Hepatitis due to VL is one of the causes of granulomatous hepatitis rarely described in the literature. It poses a problem of differential diagnosis with other causes, notably infectious and autoimmune. Hence the need for a global clinical, biological, and histological evaluation to orientate this entity, especially in endemic countries like ours. In the present case study, a 2-year 8-month-old boy was diagnosed with VL and treated with meglumine antimoniate; the evolution was marked after 2 months by the persistence of a large liver; laboratory results showed elevated liver functions and anemia. A liver biopsy was performed, and the histological findings confirmed the diagnosis of granulomatous hepatitis.

Granulomatous liver diseases

A granuloma is a discrete collection of activated macrophages and other inflammatory cells. Hepatic granulomas can be a manifestation of localized liver disease or be a part of a systemic process, usually infectious or autoimmune. A liver biopsy is required for the detection and evaluation of granulomatous liver diseases. The prevalence of granulomas on liver biopsy varies from 1% to 15%. They may be an incidental finding in an asymptomatic individual, or they may represent granulomatous hepatitis with potential to progress to liver failure, or in chronic disease, to cirrhosis. This review focuses on pathogenesis, histological features of granulomatous liver diseases, and most common etiologies, knowledge that is essential for timely diagnosis and intervention.

Hepatic granulomas following liver transplantation: A retrospective survey, and analysis of possible microbiological etiology

BACKGROUND

Liver granulomas have always been a diagnostic challenge for pathologists. They have been described in up to 15% of liver biopsies and can also be seen in liver allograft biopsy specimens, but there is a paucity of information regarding the prevalence and associated etiologic factors of granulomas in liver transplanted patients. The aim of this study is to shed light on the etiology of liver granulomas.

METHODS

Liver biopsies from liver transplanted patients, in the period from 01.01.2011 - 01.05.2017, were examined. We registered the histo-morphological characteristics and clinicopathological data of all biopsies and performed next-generation sequencing (NGS) to detect possible pathogens (bacteria, fungi, and parasites) in the biopsies containing granulomas.

RESULTS

We reviewed a total of 400 liver biopsies from 217 liver transplant patients. Of these, 131 liver biopsies (32.8%) from 98 patients (45.2%) revealed granulomas. Most were epithelioid granulomas located parenchymal and were detected in 115 (87.7%) biopsies. We also identified 10 cases (7.6%) with both lobular and portal granulomas and six biopsies (4.5%) with portal granulomas alone. In 54 biopsies (41.2%), granulomas were found in biopsies with acute cellular rejection (ACR). Fifty (51%) patients with granulomas underwent liver transplantation for autoimmune-related end-stage liver disease (AILD). The granulomas were found most frequently in the first six months after transplantation, where patients also more often were biopsied. NGS analysis did not reveal any potential infectious agent, and no significant differences were observed in the microbiological diversity (microbiome) between clinical- and granuloma characteristics concerning bacteria, fungi, and parasites.

CONCLUSION

Our study confirmed that granulomas are frequently seen in liver allograft biopsy specimens, and most often localized in the parenchyma, occurring in the first post-transplant period in patients with AILD, and often seen simultaneously with episodes of ACR. Neither a specific microbiological etiological agent nor a consistent microbiome was detected in any case.

Diagnostic value of elevated serum angiotensin-converting enzyme and lymphopenia in patients with granulomatous hepatitis

BACKGROUND AND AIM

Granulomatous hepatitis (GH) is associated with various aetiologies, especially inflammatory and infectious disorders. Sarcoidosis is a granulomatous disease in which the liver is the fourth most affected organ. Since epithelioid cell granulomas are not specific to sarcoidosis and since most patients with hepatic sarcoidosis are asymptomatic, valuable diagnostic biomarkers are needed to support the diagnosis of sarcoidosis. This study proposes to assess the diagnostic value of serum angiotensin converting enzyme (sACE) and lymphopenia in GH for sarcoidosis.

METHODS

We retrospectively analyzed the records of 90 patients referred to the internal medicine or hepatogastroenterology departments of the Lyon University Hospital (Lyon, France) between March 2002 and January 2020 in a context of GH.

RESULTS

In our tertiary center, 38 patients with sarcoidosis were identified among 73 patients with GH. Lymphopenia had a high specificity (85.7%), which increased when combined with elevated (97.0%). Interestingly, specificity increased in patients under 50 years old (100%).

CONCLUSIONS

Those results suggests that lymphopenia and sACE may be valuable biomarkers for sarcoidosis diagnosis in GH when combined, especially in younger patients.

A Pattern-Based Approach to Hepatic Infections

The evaluation of liver biopsies for infection can be a challenging and frustrating situation for diagnostic pathologists as well as clinicians. Patients often present with nonspecific symptoms, such as fever and elevated transaminases, leading to a broad differential diagnosis that typically includes malignancy and noninfectious inflammatory diseases in addition to infections. A pattern-based histologic approach can be extremely helpful in both making a diagnosis and guiding the next steps for the evaluation of the pathology specimen as well as the patient. This review discusses several of the more commonly encountered histologic patterns associated with hepatic infectious diseases, the most common pathogens with which they are associated, and helpful ancillary studies.

A surgical resection of hepatic granuloma mimicking intrahepatic cholangiocarcinoma: a case report

Hepatic granuloma is relatively rare, and benign tumor of the liver. Herein, we report an unusual case of hepatic granuloma mimicking intrahepatic cholangiocarcinoma (ICC). An 82-year-old woman with a history of viral hepatitis B was admitted for investigation of liver mass in the left lobe. Dynamic computed tomography revealed a mostly hypo-enhancing main tumor with a peripheral ring enhancement, and positron emission tomography demonstrated localized an abnormal accumulation of fludeoxyglucose. Considering the possibility of malignant disease, extended left hepatectomy was performed. The resected tumor was macroscopically a periductal infiltrating nodular type, 4.5 × 3.6 cm in diameter. The pathological findings showed that granuloma and coagulative necrosis were present, and diagnosis of hepatic granuloma was confirmed. Pathological studies demonstrated that periodic acid-Schiff stain, Grocott-Gomori stain and Ziehl-Neelsen stain were all negative in the lesion.

[Hepatic granuloma-A diagnostic challenge]

Hepatic granulomas can have various causes and their detection requires a systematic diagnostic evaluation. First, identification of risk factors for granulomatous diseases and the exclusion of extrahepatic organ manifestation are necessary. Laboratory investigations and serological screening for the most common underlying diseases of liver granulomas in Germany, such as primary biliary cholangitis (PBC), sarcoidosis and infectious causes (primarily tuberculosis and hepatitis C infections), are recommended. A liver biopsy is essential for confirming the diagnosis, whereby a minilaparoscopically guided tissue sampling offers many advantages, such as the macroscopic detection of granulomas on the liver surface, on the peritoneum or on the spleen. Whether the detection of hepatic granulomas results in a therapeutic consequence, depends decisively on the underlying primary disease. If hepatic granulomas are present without concomitant liver parenchymal damage or other manifestations that would make treatment necessary, a watch and wait approach under close clinical and laboratory monitoring is sufficient. If liver values increase or in cases of hepatic parenchymal damage, urgent treatment of the underlying disease is indicated.

Incidental Hepatic Granulomata as the Initial Presentation of Crohn's Disease in a Pediatric Patient

We describe a 9-year-old girl who presented with abdominal pain, found incidentally to have multiple liver granulomata. Extensive autoimmune and infectious workup was negative. The patient had esophagogastroduodenoscopy and colonoscopy, confirming the diagnosis of Crohn's disease. Hepatic granulomata are a rare complication of Crohn's disease and are often secondary to pharmacotherapy or infection in immunosuppressed patients. This case, to our knowledge, is the first reported case of a pediatric patient diagnosed with Crohn's disease after initially presenting with hepatic granulomata as an extraintestinal manifestation of the disease.

Focal hepatic intrinsically hyperattenuating lesions at unenhanced CT: Not always calcifications

Due to the growing use of CT, there has been an increase in the frequency of detecting focal liver lesions. Intrinsically hyperattenuating hepatic lesions or pseudolesions are not uncommon at unenhanced CT. Hyperattenuating hepatic lesions can be divided into non-calcified and calcified. Causes of intrinsic hyperattenuation include hemorrhage, thrombosis, and calcifications. Focal liver lesions can show hyperattenuation on unenhanced CT in case of severe liver steatosis. Recognition of etiologies associated with hyperattenuation on unenhanced CT can help the radiologist in characterizing focal liver lesions and pseudolesions. In this paper, we describe the spectrum of intrinsically hyperattenuating focal liver lesions and pseudolesions at unenhanced CT.

Pediatric Metastatic Crohn's Disease of the Liver

Metastatic Crohn's disease (MCD) is the manifestation of Crohn's disease outside of the gastrointestinal tract and most frequently involves mucocutaneous and pulmonary tissues. This is an uncommon phenomenon but is well characterized in the pediatric literature. In contrast, MCD affecting the liver has not previously been described in pediatrics. The pediatric gastroenterologist must be aware of the myriad of Crohn's disease-associated hepatopathies. We herein present the first reported case of pediatric MCD involving the liver and describe our targeted diagnostic evaluation and the patient's response to infliximab-dyyb.

Granulomatous Sarcoidosis Mimics

Many granulomatous diseases can mimic sarcoidosis histologically and in terms of their clinical features. These mimics include infectious granulomatous diseases, granulomatous reactions to occupational and environmental exposures, granulomatous drug reactions, vasculitides and idiopathic granulomatous conditions. It is important to distinguish sarcoidosis from these mimics, as a misdiagnosis of these diseases may have serious consequences. This manuscript reviews numerous sarcoidosis mimics and describes features of these diseases that may allow them to be differentiated from sarcoidosis. Distinguishing features between sarcoidosis and its mimics requires a careful review of the medical history, symptoms, demographics, radiographic findings, histologic features, and additional laboratory data. Understanding the clinical characteristics of sarcoidosis and its mimics should lead to more accurate diagnoses and treatment of granulomatous disorders that should improve the care of these patients. As the diagnostic criteria of sarcoidosis are not standardized, it is possible that some of these sarcoidosis mimics may represent varied clinical presentations of sarcoidosis itself.

Granuloma With an Underlying Lymphoma: A Diagnostic Challenge and a Wider Histologic Spectrum Including Adult T-Cell Leukemia/Lymphoma

Granulomatous reaction is not uncommon in histopathology, with various etiologies in different organs and geographic regions. Lymphoma is one of the underlying causes of granuloma; and sometimes the neoplastic cells may be masked by the granulomatous reaction. In this report, we present our experience with 7 lymphoma cases of various histologic types with coexisting granuloma to show the diagnostic challenges. In all cases, a granulomatous reaction was simultaneously present with the neoplastic cells. The 7 cases included 3 cases of adult T-cell leukemia/lymphoma in the lymph node or skin including one coexisting with mycobacterial infection, 2 cases of classical Hodgkin lymphoma involving the liver, and 1 case each of systemic Epstein-Barr virus-positive peripheral T-cell lymphoma and a hepatic inflammatory pseudotumor-like follicular dendritic cell sarcoma. Three cases were initially misdiagnosed as reactive change or mycobacterial infection instead of lymphoma, and a wrong histologic lymphoma type was diagnosed in 1 case. In this report, we showed that granulomatous reaction might mask lymphomas of various histologic types; and a diagnosis of mycobacterial infection or sarcoidosis could not exclude the possibility of an underlying lymphoma. We emphasized the importance of detailed histologic examination with the aid of ancillary studies to reach a correct diagnosis and to avoid inappropriate management of the patients. Our study also broadened the spectrum of lymphoma types coexisting with granuloma.

Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis

Sarcoidosis is a multi-system disease of unknown etiology characterized by the formation of granulomas in various organs. It affects people of all ethnic backgrounds and occurs at any time of life but is more frequent in African Americans and Scandinavians and in adults between 30 and 50 years of age. Sarcoidosis can affect any organ with a frequency varying according to ethnicity, sex and age. Intrathoracic involvement occurs in 90% of patients with symmetrical bilateral hilar adenopathy and/or diffuse lung micronodules, mainly along the lymphatic structures which are the most affected system. Among extrapulmonary manifestations, skin lesions, uveitis, liver or splenic involvement, peripheral and abdominal lymphadenopathy and peripheral arthritis are the most frequent with a prevalence of 25-50%. Finally, cardiac and neurological manifestations which can be the initial manifestation of sarcoidosis, as can be bilateral parotitis, nasosinusal or laryngeal signs, hypercalcemia and renal dysfunction, affect less than 10% of patients. The diagnosis is not standardized but is based on three major criteria: a compatible clinical and/or radiological presentation, the histological evidence of non-necrotizing granulomatous inflammation in one or more tissues and the exclusion of alternative causes of granulomatous disease. Certain clinical features are considered to be highly specific of the disease (e.g., Löfgren's syndrome, lupus pernio, Heerfordt's syndrome) and do not require histological confirmation. New diagnostic guidelines were recently published. Specific clinical criteria have been developed for the diagnosis of cardiac, neurological and ocular sarcoidosis. This article focuses on the clinical presentation and the common differentials that need to be considered when appropriate.

Iatrogenic hepatic granuloma (suspected liver metastatic lesion on imaging) caused by liver retraction during laparoscopic gastrectomy: A case report

There are no previous reports of hepatic granuloma secondary to intraoperative liver retraction. Using softer hepatic retraction instruments and keeping hepatic retraction time to a minimum are vital in preventing postoperative liver damage.

Sarcoidosis and Cancer: A Complex Relationship

Sarcoidosis is a systemic disease of unknown etiology, characterized by the presence of non-caseating granulomas in various organs, mainly the lungs, and the lymphatic system. Since the individualization of sarcoidosis-lymphoma association by Brincker et al., the relationship between sarcoidosis or granulomatous syndromes and malignancies has been clarified through observational studies worldwide. Two recent meta-analyses showed an increased risk of neoplasia in sarcoidosis. The granulomatosis can also reveal malignancy, either solid or hematological, defining paraneoplastic sarcoidosis. Recent cancer immunotherapies, including immune checkpoint inhibitors (targeting PD-1, PD-L1, or CTLA-4) and BRAF or MEK inhibitors were also reported as possible inducers of sarcoidosis-like reactions. Sarcoidosis and neoplasia, especially lymphoma, can show overlapping presentations, thus making the diagnosis and treatment harder to deal with. There are currently no formal recommendations to guide the differential diagnosis workup between the evolution of lymphoma or a solid cancer and a granulomatous reaction associated with neoplasia. Thus, in atypical presentations (e.g., deeply impaired condition, compressive lymphadenopathy, atypical localization, unexplained worsening lymphadenopathy, or splenomegaly), and treatment-resistant disease, targeted biopsies on suspect localizations with histological examination could help the clinician to differentiate neoplasia from sarcoidosis. Pathological diagnosis could sometimes be challenging since very few tumor cells may be surrounded by massive granulomatous reaction. The sensitization of currently available diagnostic tools should improve the diagnostic accuracy, such as the use of more “cancer-specific” radioactive tracers coupled with Positron Emission Tomography scan.

Hepatic Sarcoidosis: Current Concepts and Treatments

Hepatic sarcoidosis is a relatively common manifestation of extrapulmonary sarcoidosis. It occurs in 20 to 30% of cases and is rarely severe. However, a cluster of patients may develop severe complications such as cirrhosis and portal hypertension. In this review, we describe the current knowledge of clinical, biological, pathological, and radiological features of liver involvement in sarcoidosis and discuss essential clues for management and treatment.

A rare cause of granulomatous hepatitis: Tularemia

Tularemia is a zoonotic infection caused by Francisella tularensis. Tularemia has several clinical form in humans, including ulceroglandular, pneumonic, oropharyngeal, oculoglandular, and systemic (typhoidal). Tularemia may develop granulomatous and suppurative lesions, especially in the affected regional lymph nodes and various organs. Patients with hepatic involvement typically have elevated transaminase levels, hepatomegaly and rarely jaundice. Histologically, there are typically suppurative microabscesses with occasional surrounding macrophages. Rarely, hepatic granuloma can develop due to tularemia. We present a case of an 8 year-old male residing in a rural village in Turkey, who came to our hospital after having intermittent fever for four months and right upper abdominal pain for two months. Liver had a nodular appearance in liver imaging and liver biopsy were consistent with granulomatous hepatitis. The microagglutination test was positive for tularemia in the patient who was investigated for granulomatous hepatitis etiology. Symptoms and signs improved with tularemia treatment. We present a rare case of hepatic involvement of tularemia in a child. Clinicians should be suspicious of and evaluate for typhoidal tularemia in patients who present with prolonged fever and non-specific systemic symptoms, potentially with associated abdominal pain.

Tubercular granuloma mimicking pyogenic liver abscess

Hepatic Tuberculosis (TB) is extremely rare without miliary involvement in immunocompetent patients. Even in countries like India where TB is a major public health problem only few cases have been diagnosed and treated. We report a case of an immunocompetent patient who presented with undiagnosed pyrexia of 11 days, was initially diagnosed as pyogenic liver abscess, he did not responded to treatment and on liver biopsy was diagnosed as hepatic tuberculoma. Antitubercular treatment (ATT) was started and the patient responded well. We concluded that though hepatic TB is rare in immunocompetent patient, it is important to keep it as a differential diagnosis in patients of liver abscesses who are not responding to treatment in order to avoid needless investigations.

Multisystemic sarcoidosis-important lessons learnt from one of the great imitators

We report a case of a woman who was admitted with a suspicion of metastatic malignancy of unknown primary origin. A few months prior to her admission, she presented to a rheumatologist with acute anterior uveitis, psoriasiform rashes and polyarthritis. A diagnosis of psoriatic arthropathy was made and she was treated accordingly. Soon after she presented with persistent back and right upper quadrant abdominal pain for which she had a CT scan done with evidence of hilar lymphadenopathy, liver hypodensities and lytic-sclerotic bone lesions. She was referred to our hospital for further investigations and management. After re-exploring her clinical presentation and further investigations (including a liver biopsy), a diagnosis of multisystemic sarcoidosis with ocular, reticuloendothelial, hepatic and skeletal involvement was made. The patient was started on systemic glucocorticoids and second line immunosuppressants and demonstrated significant clinical improvement with resolution of her liver granulomata on imaging and improvement in her back pain. The case illustrates the importance of a thorough clinical assessment, review of investigations and an open mind in the evaluation of a patient.

Granulomas in the Liver, with a Focus on Infectious Causes

Hepatic granulomas are encountered in approximately 2% to 10% of liver biopsies. There are many potential infectious and noninfectious causes; granulomas can be generally classified by their morphology, which may be helpful in refining the differential diagnosis. This article provides a review of hepatic granulomas with an emphasis on infectious causes.

Hepatic granulomas: a 17-year single tertiary centre experience

AIMS

Hepatic granulomas have an estimated prevalence of 5% in liver biopsies, with a wide range of aetiologies globally. Our aim was to assess the clinical relevance, presenting features and underlying aetiology in a non-transplant, tertiary referral centre from a western country.

METHODS AND RESULTS

This was a retrospective, single-centre review of clinical, laboratory and histological data including all adult patients for whom a liver biopsy was performed from January 1998 to December 2014. A total of 297 cases with hepatic granulomas were found in 9374 biopsies, but 57 were excluded from analysis either because they were lipogranulomas or the biopsy/aetiological work-up had not been performed at our institution. Overall, the most common aetiology was tuberculosis (35.8%), followed by primary biliary cholangitis (PBC) - 15.0%. In 30 patients (12.5%) granulomas were classified as idiopathic. From 1998 to June 2006 there were 147 granulomas in 5304 biopsies (2.8%), a frequency that did not change significantly compared to the period from July 2006 to December 2014 (93 granulomas in 4070 biopsies, 2.3%, P > 0.05). However, for the majority of cases (61.9%) there was a shift in granuloma aetiology during the former time-period that infectious diseases were responsible, whereas in the latter, autoimmune liver diseases (43%) were the main aetiology. In addition, while three cases of drug-induced granulomas were found from 1998 to June 2006, we report two cases in the second time-period.

CONCLUSIONS

Hepatic granulomas can result from various infectious and non-infectious diseases. During recent years, an epidemiological shift regarding granuloma aetiology was observed, from systemic infectious diseases to non-infectious, mainly immune-mediated primary liver disorders. With an appropriate work-up the aetiology can be identified in the vast majority of cases (~90%), rendering its histological identification and characterisation essential, as disease-specific therapies are becoming available.

Allopurinol-Induced Granulomatous Hepatitis: A Case Report and Review of Literature

Liver enzyme elevation is a common reason for referral to a gastroenterologist. Drugs are one of the most common reasons for asymptomatic elevation of liver enzymes. We present here a case of granulomatous hepatitis (GH) secondary to long-term use of allopurinol. An 83-year-old male with a history of chronic gout and hypertension was evaluated for elevation of liver enzymes. He denies any complaints of abdominal pain, nausea, fever, chills, weight loss, night sweats, or yellowness of skin. He denies any use of herbal medications. He was on losartan and allopurinol for years. No new medications reported. Physical examination was unremarkable. Labs showed aspartate transaminase 101 U/L, alanine transaminase 81 U/L, and alkaline phosphatase 645 U/L. Ultrasound of the abdomen showed coarse liver texture. Liver biopsy was done that showed mixed GH. Given negative autoimmune and viral serologies, allopurinol-induced GH was suspected. Allopurinol was held, and repeat liver enzymes were checked in 3 months, which showed improvement in transaminase and alkaline phosphatase levels. This case highlights the importance of reviewing medications carefully when evaluating a patient with liver enzymes elevation, as stopping the offending drug can normalize the abnormalities in liver chemistries and can prevent subsequent expensive testing.

Tuberculosis of the Liver, Biliary Tract, and Pancreas

Tuberculosis of the liver, biliary tract, and pancreas is discussed. In addition, tuberculosis in the setting of HIV-AIDS and liver transplantation is explored. Drug-induced liver injury secondary to antituberculosis medication and monitoring and prophylactic treatment for such injury is also considered.

The presence of donor liver granuloma requiring further workup to rule out parasitic disease

A shortage of donor organs is a major limitation to liver transplantation. Expansion of donor pool criteria to include patients with schistosomiasis diagnosed on liver biopsy might allow the allocation of more transplant livers. Schistosomiasis is a chronic parasitic disease affecting millions in endemic areas including sub-Sahara Africa that might lead to the development of granulomas as a response to the parasite’s ova and might cause chronic liver disease and portal hypertension. Due to increased mobility globally, schistosomiasis may be encountered in non-endemic areas. Currently, the usage of donor livers with known Schistosomiasis is not universally defined.

The histopathological evaluation of drug-induced liver injury

Drug-induced liver injury (DILI) presents unique challenges to the pathologist. It is not only an uncommon reason for liver biopsy, but the pathology of DILI is spread across the entire spectrum of hepatic injury patterns. It is important for the pathologist to suspect DILI when the histological changes are unusual or out of synchronicity with the patient's history. A systematic evaluation approach will yield the most information. It begins with the characterization of the general pattern of injury which, for most cases, will be found in a handful of necroinflammatory and cholestatic patterns. A careful assessment of the severity of injury across the various anatomic compartments will provide information on the probable natural history of the injury. Correlation of liver injury with the patient's medication history and clinical findings will help to narrow the differential diagnosis, particularly when it is recognized that most drugs have a limited range of histological findings and vary in their propensity to cause injury. This review provides an overview of the assessment of the liver biopsy and its use to confirm or exclude particular drugs as contributing to the patient's liver injury.

Onset of Tuberculosis from a Pulmonary Latent Tuberculosis Infection during Antiviral Triple Therapy for Chronic Hepatitis C

A 62-year-old man was diagnosed with the onset of tuberculosis (Tb) from a pulmonary latent tuberculosis infection (LTBI) during triple therapy with pegylated interferon α2a, ribavirin, and telaprevir for a chronic hepatitis C infection in 2013 before interferon (IFN)-free anti-viral therapy was introduced in Japan. A liver biopsy before IFN treatment revealed the presence of epithelioid cell granulomas (ECGs). IFN may also be employed for chronic hepatitis B infection and malignant tumors, thus, special attention must be paid to the development of Tb from a LTBI when ECGs are observed before treatment. It is also necessary to review the significance of the liver biopsy.

Hepatic Granulomas: A Review With Emphasis on Infectious Causes

CONTEXT

Many diseases that cause granulomas or granulomatous inflammation involve the liver. Some of these disease processes are intrinsic hepatic diseases, whereas others are disseminated systemic diseases that involve the liver as well as other organs.

OBJECTIVE

To review the evaluation of granulomas in the liver with an emphasis on infectious causes, as well as the use of special stains, serologic studies, and molecular diagnostic techniques. Pertinent noninfectious causes of hepatic granulomas that are in the differential diagnosis are also discussed.

DATA SOURCES

Literature review and cases acquired during years of practice.

CONCLUSIONS

A wide variety of infectious and noninfectious entities cause hepatic granulomas.

Extrahepatic biliary obstruction: an unusual presentation of hepatic sarcoidosis

We report this case of a 63-year-old woman who presented with progressive illness characterized by abdominal pain, weight loss, anorexia, generalized weakness, and fatigue. The patient was found to have obstructive jaundice with multiple mass lesions in the liver, spleen, and kidney on computed tomography scan of abdomen. She developed cholangitis, necessitating an emergent endoscopic retrograde cholangiopancreatography with biliary stenting and decompression. Later, she was found to have hepatic sarcoidosis on wedge biopsy of the liver. Extrinsic compression of biliary tree from mass effect of sarcoid granulomas with superimposed biliary sepsis is rare.

Clinical presentation and protocol for management of hepatic sarcoidosis

The liver is one of the most commonly involved extrapulmonary sites in sarcoidosis. Hepatic sarcoidosis has a broad range of presentations from scattered, asymptomatic noncaseating granulomas with normal liver enzymes, which are very common in patients with known pulmonary sarcoidosis, to portal hypertension and cirrhosis, which are relatively uncommon. Diagnosis is based on a combination of clinical, laboratory and histological manifestations. The authors' protocol for management of patients with suspected sarcoidosis of the liver without focal lesions includes a transjugular liver biopsy with portal pressure measurements to confirm the diagnosis, rule out coexisting liver diseases and to identify select patients with fibrosis or portal hypertension for consideration of immunosuppression. Steroids and azathioprine are the preferred agents and methotrexate is not recommended.

Co-occurrence of idiopathic granulomatous hepatitis and primary biliary cirrhosis

BACKGROUND

PBC is an autoimmune disease affecting the bile ducts. Granulomas can be found in portal triads in 45 % of patients with PBC. Idiopathic granulomatous hepatitis is a rare disease of unknown cause which is characterized by recurrent fevers, sweats, elevated levels of liver enzyme tests, particularly the serum alkaline phosphatase, and granulomas in the portal and lobular regions of the liver. Previous literature suggests that a diagnosis of idiopathic granulomatous hepatitis can be made only if PBC has been excluded.

STUDY

We reviewed instances in which PBC and idiopathic granulomatous hepatitis occurred in the same patient.

RESULTS

We report three patients in whom both diseases occurred: 1) A patient with PBC who was diagnosed 15 years later with idiopathic granulomatous hepatitis; 2) A patient with idiopathic granulomatous hepatitis who developed PBC 12 years later; and 3) A patient who had features of both idiopathic granulomatous hepatitis and PBC at the time of initial diagnosis.

CONCLUSIONS

Our experience with these patients suggests that idiopathic granulomatous hepatitis and PBC can occur in the same individual. Knowing this association is important, as clinical deterioration in a patient with either disease could suggest the presence of the other and should be treated accordingly.

Histopathologic manifestations of drug-induced hepatotoxicity

Drug-induced hepatotoxicity is underrecognized but increasingly identified as causing acute and chronic liver disease. Several prescription drugs, over-the-counter medications, dietary and/or supplementary agents, and herbal products are hepatotoxic. Drug-induced liver injury mimics other primary acute and chronic liver diseases and it should be considered in patients with hepatobiliary disease. Certain drugs result in specific histopathologic patterns of liver injury, which may help in sorting out the responsible drug. The diagnosis of drug-induced hepatotoxicity is challenging. It involves excluding other possible causes, careful medication history, the latent period between drug exposure and symptom onset and/or abnormal liver tests, and histopathologic findings.

Hepatic sarcoidosis complicating treatment-naive viral hepatitis

Hepatic sarcoidosis is usually asymptomatic but rarely leads to adverse liver-related outcome. Co-existence of viral hepatitis and hepatic sarcoidosis is a rare, but recognised phenomenon. Obtaining a balance between immune suppression and anti-viral therapy may be problematic. Immunosuppression in the presence of viral hepatitis can lead to rapid deterioration of liver disease. Similarly, anti-viral therapy may exacerbate granulomatous hepatitis. Here we present two cases of viral hepatitis co-existing with sarcoidosis that illustrate successful management strategies. In one, hepatitis B replication was suppressed with oral anti-viral therapy before commencing prednisolone. In the second, remission of hepatic sarcoidosis was achieved with prednisolone, before treating hepatitis C and obtaining a sustained virological response with pegylated interferon and ribavirin therapy.

Delayed enhanced hepatosplenic sarcoid nodules on computed tomography in an interferon-naïve hepatitis C patient: a case report and review of the literature

A 77-year-old woman with chronic type C hepatitis was diagnosed with hypoechoic hepatosplenic nodules on ultrasonography. These lesions showed low density on precontrast computed tomography and delayed enhancement. Judging from laboratory data and images, the nodules were considered unlikely to represent malignancies and were followed conservatively. The hepatic lesions then increased in size and number. Sarcoidosis was diagnosed following liver biopsy. All nodules disappeared spontaneously within 6 years. Although some cases of interferon-induced sarcoidosis in patients with chronic hepatitis C or hepatitis C virus (HCV)-related cirrhosis have been reported recently, interferon-naïve cases are relatively rare. Delayed enhancement on computed tomography may reflect fibrosis of hepatic sarcoid lesions that have been histologically confirmed. Gastroenterologists managing patients with chronic HCV infection need to keep such cases in mind.

Sarcoidosis and chronic hepatitis C: A case report

Several case reports deal with the relationship between hepatitis C virus (HCV) infection and pulmonary or hepatic sarcoidosis. Most publications describe interferon α-induced sarcoidosis. However, HCV infection per se is also suggested to cause sarcoidosis. The present case report describes a case of biopsy-verified lung and liver sarcoidosis and HCV infection, and the outcome of antiviral therapy. In March 2009, a 25-year-old man presented with moderately elevated liver enzymes without any clinical symptoms. The patient was positive for HCV antibodies and HCV RNA of genotype 1b. Four months later the patient became dyspnoic and pulmonary sarcoidosis was diagnosed by lung biopsy and radiography. A short course of corticosteroid treatment relieved symptoms. Three months later, liver biopsy showed noncaseating granulomas consisting of epithelioid histiocytes and giant cells with a small amount of peripheral lymphocyte infiltration, without any signs of fibrosis. Chronic HCV infection with coexistence of pulmonary and hepatic sarcoidosis was diagnosed. Antiviral therapy with peginterferon α and ribavirin at standard doses was started, which lasted 48 wk, and sustained viral response was achieved. A second liver biopsy showed disappearance of granulomas and chest radiography revealed normalization of mediastinal and perihilar glands. The hypothesis that HCV infection per se may have triggered systemic sarcoidosis was proposed. Successful treatment of HCV infection led to continuous remission of pulmonary and hepatic sarcoidosis. Further studies are required to understand the relationship between systemic sarcoidosis and HCV infection.

Diagnosis and treatment of hepatic sarcoidosis

The presence of granulomas in the liver raises consideration of a wide differential diagnosis, but in most Western series, sarcoidosis accounts for a majority of cases. This review will focus specifically on the diagnosis of and therapy for hepatic sarcoidosis. Sarcoidosis is a systemic granulomatous disease of unknown etiology. Hepatic involvement of sarcoidosis was described in 11.5% of 736 patients enrolled in the ACCESS study. However, presence alone of granulomas in an organ in sarcoidosis does not dictate treatment. The decision to treat should be based on symptoms and severity of disease. Although hepatic involvement usually is asymptomatic, a minority of patients progress to chronic cholestatic disease, portal hypertension, and cirrhosis that may require liver transplantation. Treatment of hepatic sarcoidosis should be reserved for patients who manifest this spectrum of disease. Glucocorticoid treatment is first-line therapy for hepatic sarcoidosis, improving symptoms and abnormal laboratory values but generally having no effect on progression of disease. In addition to glucocorticoids, immunomodulators such as azathioprine, methotrexate, hydroxychloroquine, and infliximab have been used with some positive effects on symptoms, liver enzyme abnormalities, and hepatomegaly, but none has been shown to prevent progression of disease. Ultimately, in cases of overt liver failure, liver transplantation is the definitive treatment. Overall, treatment for hepatic sarcoidosis is targeted toward alleviation of symptoms but has no curative potential at this time. Focus should be on discovering the etiology of the disease to target therapy at prevention, not cure.

Role for mycobacterial infection in pathogenesis of primary biliary cirrhosis?

Primary biliary cirrhosis (PBC) is a progressive cholestatic liver disease characterized by the immune-mediated destruction of biliary epithelial cells in small intrahepatic bile ducts. The disease is characterized by circulating antimitochondrial antibodies (AMAs) as well as disease-specific antinuclear antibodies, cholestatic liver function tests, and characteristic histological features, including granulomas. A variety of organisms are involved in granuloma formation, of which mycobacteria are the most commonly associated. This has led to the hypothesis that mycobacteria may be involved in the pathogenesis of PBC, along with other infectious agents. Additionally, AMAs are found in a subgroup of patients with mycobacterial infections, such as leprosy and pulmonary tuberculosis. Antibodies against species-specific mycobacterial proteins have been reported in patients with PBC, but it is not clear whether these antibodies are specific for the disease. In addition, data in support of the involvement of the role of molecular mimicry between mycobacterial and human mitochondrial antigens as triggers of cross-reactive immune responses leading to the loss of immunological tolerance, and the induction of pathological features have been published. Thus, antibodies against mycobacterial heat shock protein appear to cross-recognize AMA-specific autoantigens, but it is not clear whether these autoantibodies are mycobacterium-species-specific, and whether they are pathogenic or incidental. The view that mycobacteria are infectious triggers of PBC is intriguing, but the data provided so far are not conclusive.

Limited yield of diagnoses of intrahepatic infectious causes of canine granulomatous hepatitis from archival liver tissue

Canine granulomatous hepatitis is an uncommon morphologic diagnosis that has been associated with a variety of diseases, including a number of systemic infectious etiologies. Formalin-fixed, paraffin-embedded (FFPE) tissues are typically the only source of liver tissue remaining for additional testing for the presence of infectious disease within granulomas. It is unclear if the more common infectious culprits of granulomatous hepatitis can be identified from such specimens. The aim of the current study was to retrospectively investigate archival FFPE liver tissue from dogs with granulomatous hepatitis for the presence of infectious agents. Semiquantitative analysis of copper accumulation in liver specimens was also performed. Medical records were examined for recorded evidence of systemic infectious disease diagnosis. Formalin-fixed, paraffin-embedded liver was prospectively evaluated for infectious agents via differential staining techniques (n = 13), eubacterial fluorescent in situ hybridization (n = 11), and Bartonella polymerase chain reaction assays (n = 15). An infectious cause of granulomatous hepatitis was not identified within liver tissue from any dog using these diagnostic methodologies. Six out of 25 (24%) dogs were diagnosed with concurrent systemic or localized bacterial infections at the time of presentation. Nine out of 17 (53%) dogs had excessive hepatic copper accumulation when evaluated by a semiquantitative histologic grading scheme or quantitative copper analysis. As definitive infectious causes of granulomatous hepatitis were not identified within archival liver biopsy samples, it was concluded that investigation of infectious etiologies within FFPE liver specimens using these diagnostic approaches may be of low yield.

Granulomatous liver disease

Hepatic granulomata are not infrequently encountered in liver biopsy and often are associated with systemic disease. The clinical presentation varies with the particular systemic process. From a biochemical standpoint, the most common abnormalities are elevated serum alkaline phosphatase and γ-glutamyltransferase. The observation of granulomata in a liver biopsy specimen warrants workup to identify a possible cause. Clues may be obtained in the medical history, on physical examination, or with specialized blood testing or radiologic studies. Treatment involves therapy of the underlying cause of the disease associated with the development of the granulomatous hepatitis.

Budd-Chiari syndrome as presenting symptom of hepatic sarcoidosis in a child, with recurrence after liver transplantation

A seven-yr-old boy presented with a severe Budd-Chiari syndrome, complicated by recurrent thrombosis of several successive TIPSs. Because of liver failure secondary to venous outflow tract obstruction and deterioration of his general condition, an emergency liver transplantation was performed. Steroids were discontinued three months after transplantation, and maintenance immunosuppressive therapy consisted of tacrolimus and azathioprine. Seven years later, this patient presented symptoms of recurrence of venous outflow obstruction in the transplant liver, comparable to the initial event. Histopathology of the liver revealed diffuse granulomatous inflammation with confluent non-caseating granulomas compressing the centrolobular veins. Extensive investigations excluded infections, immune deficiency, and systemic vasculitides. After treatment with a high dose of corticosteroids, the granulomas in the allograft disappeared completely. We report the first case of hepatic sarcoidosis, presenting with venous outflow obstruction and recurring after liver transplantation, in a child.

Pulmonary and hepatic nodular lesions precede the diagnosis of Crohn's disease in an 8-year-old girl: a case study and review of the literature

AIM

To describe a novel clinical observation and to provide a review the literature about lung involvement in children with Crohn disease (CD).

METHODS

An 8-year-old girl presented with pulmonary and hepatic granulomatous lesions, followed 6 months later by abdominal and general symptoms, resulting in the diagnosis of CD. Differential diagnosis between CD and sarcoidosis and a review of the literature about lung lesions in children with CD are discussed.

RESULTS

Crohn disease can be associated with pulmonary lesions, developing before, at the same time or after occurrence of digestive symptoms.

CONCLUSIONS

This report highlights not only the importance of looking for lung lesions in CD but also underscores the necessity of considering the diagnosis of CD in incomplete presentation evoking sarcoidosis.

Tuberculosis Is Not a Risk Factor for Primary Biliary Cirrhosis: A Review of the Literature

Primary biliary cirrhosis (PBC) is a progressive cholestatic liver disease characterised serologically by cholestasis and the presence of high-titre antimitochondrial antibodies, and histologically by chronic nonsuppurative cholangitis and granulomata. As PBC is a granulomatous disease andMycobacterium tuberculosisis the most frequent cause of granulomata, a causal relation between tuberculosis and PBC has been suggested. Attempts to find serological evidence of PBC-specific autoantibodies such as AMA have been made and, conversely, granulomatous livers from patients with PBC have been investigated for molecular evidence ofMycobacterium tuberculosis. This paper discusses in detail the reported data in support or against an association betweenMycobacterium tuberculosisinfection and PBC. We discuss the immunological and microbiological data exploring the association of PBC with exposure toMycobacterium tuberculosis. We also discuss the findings of large epidemiologic studies investigating the association of PBC with preexistent or concomitant disorders and the relevance of these findings with tuberculosis. Genome-wide association studies in patients with tuberculosis as well as in patients with PBC provide conclusive hints regarding the assumed association between exposure to this mycobacterium and the induction of PBC. Analysis of these data suggest thatMycobacterium tuberculosisis an unlikely infectious trigger of PBC.

New insights into gastrointestinal and hepatic granulomatous disorders

Numerous diseases that involve the gastrointestinal tract reveal the presence of granulomas on histological analysis. Granulomatous diseases can be either primary or secondary to environmental factors. Granulomas are dynamic structures composed of organized collections of activated macrophages, including epithelioid and multinucleated giant cells, surrounded by lymphocytes. The formation of granulomas is usually in response to antigenic stimulation and is orchestrated through cytokines, immune cells and host genetics. In this Review, the pathogenesis and etiologies of granulomas of the gastrointestinal tract and liver are discussed, as are the available diagnostic tools to help differentiate their various underlying etiologies. In addition, the role of granulomas in harboring latent tuberculosis is reviewed. The effects of tumor necrosis factor antagonists and interferon-α on the development of granulomas are also discussed.