Macronodular Hepatic Tuberculosis Necessitating Hepatic Resection: A Diagnostic Conundrum

• Published in: Canadian Journal of Surgery 2007-10, Vol.50 (5), p.E7-E8
• Main Authors: Vimalraj, Velayutham, MS, Jyotibasu, Damodaran, MS, Rajendran, Shanmugasundaram, MCh, Ravichandran, Palaniappan, MCh, Jeswanth, Satyanesan, MCh, Balachandar, Tirupporur Govindaswamy, MCh, Kannan, Devy Gounder, MCh, Surendran, Rajagopal, MCh
• Format: Article
• Language: English
• Subjects: Abdominal Pain - etiology; Adult; Analysis; Case Note; Case studies; Diagnosis; Diagnosis, Differential; Humans; Laparoscopy; Liver diseases; Liver Neoplasms - diagnosis; Male; Medical diagnosis; Medical imaging; Surgery; Tuberculosis; Tuberculosis, Hepatic - complications; Tuberculosis, Hepatic - diagnosis; Tuberculosis, Hepatic - surgery
• ISSN: 0008-428X; 1488-2310
• DOI: 10.1016/S0008-428X(07)50134-7

A 30-year-old man presented with complaints of upper abdominal pain for 1 month and significant weight loss. He denied drinking alcohol and smoking. He was thin and anicteric. No abnormality was seen on abdominal examination, esophagoduodenoscopy or colonoscopy. His hemoglobin was 11.8 g/L, total count 9.5 × 109/L, the differential count showed 65% polymorphs, 38% lymphocytes and 2% eosinophils; liver function test findings were within normal limits. The serum a-fetoprotein was 2.31 ng/mL (normal range 0-9.0 ng/mL), the carcinoembryonic antigen level was 1.47 ng/mL (normal range 0-3.0 ng/mL); and viral markers for hepatitis B and hepatitis C were negative. Ultrasonography showed a solid-appearing confluent hypoechoic mass lesion in segments 6 and 7 of the right hepatic lobe, measuring 8 × 5 cm. Contrast-enhanced CT showed a hypodense lesion with marginal nodular enhancement after intravenous injection of contrast in the arterial phase and filling of the pattern of enhancement with persistent opacification in venous and delayed phases, involving segments 6 and 7. MRI showed multiple, rounded, discrete and confluent space-occupying lesions that were hypointense in T1-weighted images and isointense to liver parenchyma on T2-weighted images. Lesions demonstrated a peripheral rim on T2-weighted images. On heavilyweighted images, the lesions did not demonstrate increased signal intensity, which was similar to conventional T2- weighted images. Fine-needle aspiration of the lesion gave inconclusive results. Diagnostic laparoscopy revealed a nodular lesion 5 × 3 cm in size in segment 6 and another nodular lesion 3 × 3 cm in segment 5 in the right hepatic lobe. A classical right hepatectomy was performed (Fig. 1). Histopathological examination of the excised specimen showed multiple foci of epitheloid granulomata with necrosis bordered by multinucleate giant cells (Fig. 2). The surrounding liver parenchyma showed lymphocytic infiltration within the portal tracts with occasional eosinophils.