case report hepatic tb
TRANSCRIPT
7/27/2019 Case Report Hepatic TB
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7/27/2019 Case Report Hepatic TB
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Hepatic TBCase Report
BY
Dr Samy Zaky / Dr Nabiele El-Nohmany
MDTropical Medicine
Al-Azhar University
7/27/2019 Case Report Hepatic TB
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Case Report•
A 26-year-old engineering presented with 5 month
history of upper abdominal pain, dyspepsia,&weight loss.
• Clinical examination: fever, epigastric & right
upper quadrant tenderness, with a smooth tender
4 cm hepatomegaly.
• Initial blood results revealed:
- a microcytic anemia (Hb 10.3 g/dL, MCV 73.4 fl),
-raised inflammatory markers (ESR 126, CRP 178mg/L),
-an elevated alkaline phosphatase (153 IU/L).
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Contrast enhanced
abdominal CT scan-6 x 5 cm mixedattenuating lesionin the left lobe,
-4cm lesion in theright lobe of theliver.
Abdominal ultrasound: a 6.5-cm
heterogenous mass in the left lobe of the
liver suggestive of HCC.
The appearances:
suggestive of either lymphoma or HCC.
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Serum tumour markers
AFP, CEA, CA 19-9: were
normal
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HFL by US &|or
AFP > 200
M.
Triphasic
Helical CT
Conclusive*
Not conclusive
Tumor size
>
2
cm
AFP>
200 AFP<
200
Liver biopsy
<
2
cm
II- Diagnosis
* Hypervascularity :in arterial phase & washout in the early or delayed
venous phase) Samy zaky
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Histology revealedgranulomatous
inflammation
associated withLanghans giant cells
suggesting
mycobacterial
infection.a granulomatous inflammation,
little preservation of liver architecture,
and presence of Langhans cells (arrow).
(200× magnification, H and E stain)
a guided liver biopsy:
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Aspiration of 100 mL of thick purulent
material was performed under ultrasound
guidance. Although Ziehl-Nielsen stain failed to
demonstrate acid-fast bacilli, culture
demonstrated the presence of Mycobacterium tuberculosis, sensitive to
quadruple therapy.
•
Plain chest radiology & thoracic CT: noevidence of pulmonary TB.
• HIV serology was negative.
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• The patient was commenced on
ethambutol, isoniazid, pyrazinamide, and
rifampicin.
• Within 3 months of therapy, the patient
was asymptomatic with normal serum
inflammatory markers.
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Repeat CT scan following 6 months
of antituberculous therapy revealed
a complete resolution of the lesions.
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Hepatic TB
Hepatic involvement can be seen inup to 80% of disseminated casesof TB.
Isolated tuberculous involvement of the liver is considered rare (lowO2 tension within the liver)
Primary hepatic TB in absence of immunocompromise is extremelyrare.
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Hepatic TB
(a) Miliary TB;
(b) pulmonary TB with hepaticinvolvement;
(c) primary liver TB;
(d) focal tuberculoma or abscess; or
(e) tuberculous cholangitis.
Hepatic TB has been classified by
Levine into:
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• Tuberculous cholangitis may
present with jaundice & fever.• Focal liver abscess: right upper
quadrant abdominal pain, fever,
night sweats, anorexia, and weightloss.
The most frequent examination findings
include abdominal tenderness with or without a palpable mass & occasional
jaundice.
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Laboratory investigations often reveal
• an elevated alkaline phosphatase
•
normal ALT and AST.• Less specific findings include anemia,
hypoalbuminemia, and hyponatremia.
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Imaging studies can pose a diagnosticchallenge, with many DD, including primaryHCC.
• US: Hypoechoic nodules are usually seen.
• CT findings: usually reveal a round hypodenselesion with slight peripheral enhancement and,occasionally, areas of focal calcification.
• Noninvasive diagnosis is therefore difficult, and
• up to 90% of cases require a laparotomy to
make the diagnosis. • primary hepatic tuberculoma (rare) should be
considered among the DD of space-occupyinglesions of the liver .
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• The histologic findings often achievethe diagnosis, with features of caseating
granulomatous necrosis.Langhans-type giant cells are often present
with a mixed inflammatory infiltrate
including plasma cells, eosinophils, &lymphohistiocytic cells.
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• Low sensitivity of both acid-fast staining
(0-45%) and culture (10-60%) mean
diagnosis can still be difficult.
However, the use of PCR to directly detect
Mycobacterium tuberculosis and other
recent investigations are increasing and
may improve sensitivity rates.
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Treatment of hepatic TB
• quadruple therapy for 1 year, and signs of clinical improvement within 2-3 months appear.
•
The use of percutaneous drainage has alsobeen advocated.
• Mustard and colleagues suggested featuresassociated with successful drainage included:
(1) unilocular abscess;(2) safe access route for instillation of drainagecatheter; and
(3) a sterile uncontaminated compartment.
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