Pseudotumor tuberculosis of liver : a rare entity

We present a rare case of a 46-year-old man who presented with recurrent fever and abdominal pain without other symptoms. Laboratory data were no specific for diagnosis. Abdominal imaging revealed a pseudotumor liver. A diagnosis of isolated liver tuberculosis with abscess component was confirmed with US-guided liver biopsy and histopathological examination. The patient received antibacillous drugs with success. DOI : COMING SOON Keys words: tuberculosis, Liver, pseudotumor, antibacillous drugs. Corresponding Author: Mehdi Soufi, MD, Division of digestive and oncological Surgery, Oujda CHU, faculty of medicine. University Mohammed first Bp 4847 Oujda université 60049, Oujda Morocco (Tel: +212661212924; Email: drsoufimehdi@hotmail.fr) Running title : PTL Received Jul 30, 2014; Accepted Nov 11, 2014; Published Feb 12, 2015; Freely Available Online www.openaccesspub.org | JSLR CC-license DOI : coming soon Vol-1 Issue 1 Pg. no.2 Introduction: Tuberculosis is one of the most common diseases in Morocco [1]. Although the prevalence of tuberculosis decreased quickly worldwide after the widespread use of antibacillous drugs, the prevalence has increased in recent years in immunocompromised and immunocompetent patients [1]. Hepatic tuberculosis is an uncommon form of extrapulmonary tuberculosis. It is usually a disseminated disease associated with military tuberculosis, which is one of the most characteristic manifestations of tuberculosis. Localized tuberculosis of the liver in the pseudotumor form is rare [2]. We report a rare case of isolated liver tuberculosis in young patient without any immunodeficiency treated successfully with antibacillous drugs.


Introduction:
Tuberculosis is one of the most common diseases in Morocco [1].Although the prevalence of tuberculosis decreased quickly worldwide after the widespread use of antibacillous drugs, the prevalence has increased in recent years in immunocompromised and immunocompetent patients [1].Hepatic tuberculosis is an uncommon form of extrapulmonary tuberculosis.It is usually a disseminated disease associated with military tuberculosis, which is one of the most characteristic manifestations of tuberculosis.Localized tuberculosis of the liver in the pseudotumor form is rare [2].We report a rare case of isolated liver tuberculosis in young patient without any immunodeficiency treated successfully with antibacillous drugs.

Case report:
A 46 year old man was admitted with 5 months history of remittent fever ranging between 37.6°C and 38.2°C.The fever was associated with chills and epigastric pain, as well as night sweats.The patient has also a history of 10 Kg weight loss along with loss of appetite.
On clinical examination, the patient was, oriented in time and space, cooperative, febrile 37,9, anicteric and normopneic, without peripheral lymphadenopathy.He had abdominal tenderness in the epigastric region, without hepatosplenomegaly.
Laboratory analysis showed hemoglobin, 10.9 g/dL; white blood cell count, Ultrasound of abdomen showed a 10 cm hypoechogenic lesion in left liver (Figure 1).An   presents the third form as a focal local tuberculoma or abscess [5].
Tuberculosis spreads to the liver through the hepatic artery, the portal system and the lymphatic system.It commonly involves the hepatic parenchyma and sometimes the biliary tree [4,6].showed a hypoechoic rim and solitary lesion.In theses cases, it is difficult to differentiate them from carcinoma [11].
Computed tomography (CT) and magnetic resonance imaging (MRI) are helpful in diagnosis.
CT findings of tuberculosis abscesses can show lowdensity focal lesions with or without ring enhancement on contrast administration.These have also been seen in necrotic tumor such as hepatocellular, inflammatory disease and metastatic carcinoma [12].
CT-guided aspiration and biopsy can confirm the diagnosis.Percutaneous needle biopsy of the liver using ultrasound, CT has greater than 90 percent sensitivity.
In case of pseudotumor tuberculosis mimicking a carcinoma, the role of biopsy is important because it can change therapeutic attitudes.The definitive diagnosis of this disease is conventionally made by histological analysis of caseating granuloma or demonstration of acid-fast bacilli on culture of biopsy specimen [13].
Otherwise, the rate of accurate pretreatment diagnosis by guided percutaneous liver biopsy has been reported to be low, and the presence of tubercle bacilli in the biopsy sample is rare.In these cases, using polymerase chain reaction to directly detect the presence of Mycobacterium tuberculosis improves sensitivity rates [14].

Figure 4 :
Figure 4: Hepatic histopathology of patient showing granuloma

Freely
Available Online www.openaccesspub.org| JSLR CC-license DOI : coming soon Vol-1 Issue 1 Pg.no.-5CT drainage is good for the successful drainage of tubercular abscess, although surgical drainage may occasionally be required[15].The treatment of hepatobiliary tuberculosis does not differ from other extrapulmonary tuberculosis.We usually use Chemotherapy with standard antituberculosis drugs.This is true for both diffuse as well as the local forms of the disease.In general, a 6-to 9month regimen (2 months of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol followed by 4-7 months of isoniazid and rifampin) is the recommended treatment for extrapulmonary tuberculosis[3,10,16].The surgical treatment is most often indicated when a diagnosis of liver tumor is assumed.In these cases therapeutic modalities include all kinds of hepatic resection with postoperative administration of antituberculous agents[17].The prognosis remains excellent with appropriate antibacillous treatment.The Mortality rate for hepatic tuberculosis is higher in immunodeficient patient.Predictive factors of mortality are age under 20 years, miliary tuberculosis, concurrent steroid therapy, AIDS, cachexia, associated cirrhosis and liver failure[10].ConclusionLiver tuberculosis is a rare and curable disease.The clinical presentation of isolated liver tuberculosis is nonspecific.Preoperative diagnosis when it presents, as pseudotumor lesions are difficult.Histopathology is necessary for diagnosis.Because of the increasing incidence of tuberculosis, clinicians should be aware of the possibility of tuberculosis disease with liver pseudotumor.