Causes of hepatic granuloma: a 12-year single center experience from Southern Iran

Hepatic granuloma is reported in 2 - 15% of liver biopsy specimens. It is relatively easy for the pathologist to diagnose, but sometimes arriving at a specific etiology is quite difficult. Until now, there are few published studies about the etiology of hepatic granuloma in Iran. In this study, we attempt to determine the causes of hepatic granuloma from one of the largest referral centers in this country. In a retrospective study over 12 years, a hepatopathologist reviewed all liver biopsies with granuloma. The medical records, including clinical findings, autoantibodies, viral markers, imaging studies, drug histories, and all other specialized tests, such as molecular studies, were reviewed to reach a definite diagnosis. During 12 years, there were 72 cases diagnosed with liver granuloma. The most common cause of hepatic granuloma was infectious, with Mycobacterium tuberculosis [52.8%]. The second most common cause was visceral leishmaniasis in 8.3% of biopsies. Other less common causes were fungal infections, visceral larva migrans, primary biliary cirrhosis, and hepatitis C, each in 4.2% of cases. Autoimmune hepatitis was diagnosed in 2.8% of patients. Lymphoma, drug induced, disseminated BCGitis, CMV infection, foreign body reaction and sarcoidosis, were each found in 1.4% of the liver biopsies. After all investigations, there were 12.5% idiopathic hepatic granulomas. According to this study, the most common cause of hepatic granuloma in Iran is tuberculosis. This finding is completely different from western countries and very similar to the results of countries such as Saudi Arabia

Localized hepatic tuberculosis presenting as fever of unknown origin

Localized hepatic tuberculosis is a rare clinical form of tuberculosis infection; it has signs and symptoms related only to hepatic injury, with minimal or no extrahepatic involvement. It frequently presents as a non-specific syndrome, with systemic manifestations, which can sometimes result in a diagnostic dilemma. A high index of suspicion is required and a definitive diagnosis can be very difficult. We report a case of localized hepatic tuberculosis that presented as fever of unknown origin.

Liver involvement in tuberculosis--an autopsy study.

OBJECTIVE: To study the spectrum of histopathological changes in the liver in cases of tuberculosis. MATERIALS & METHODS: This is an autopsy study consisting of 150 adult cases of tuberculosis over a period of 3 years. The diagnosis of tuberculosis was made on the basis of caseating granulomas or acid fast bacilli in the tissue. Cases showing only healed foci of tuberculosis at autopsy were excluded. Clinical details of all cases were obtained from hospital records. At autopsy, gross examination was done meticulously with special emphasis on the liver and extrahepatic biliary tree. Sections from the liver were processed routinely and histopathological findings were analyzed in detail. RESULTS: Patients were between 21 to 60 years of age with a male: female ratio of 2.1:1. Fever was the commonest symptom (62%). On gross examination, at autopsy, pulmonary and extrapulmonary tuberculosis was seen in 79 (52.6%) and 71 (47.4%) cases respectively. Liver involvement was mainly secondary except in one case. The extrahepatic biliary tree was involved in 18 cases, in the form of external compression of the common bile duct by a group of enlarged caseating, matted lymph nodes. The spectrum of histopathological changes of the liver showed epitheloid cell granulomas in 63 (42%), fatty changes in 49 (32.6%), inflammation in 60 (40%), sinusoidal congestion in 48 (32%) and fibrosis in 24 (16%) cases. Of the 63 cases of liver granulomas, 12 (19%) were cases of extensive pulmonary tuberculosis and the remaining were extrapulmonary tuberculosis. Granulomas were caseating in 58.7%, noncaseating in 23.8% and atypical in 17.5% cases. Fatty change ranged from mild to severe. Inflammation was mainly mild to moderate. Stage I and II fibrosis was seen in 13 (8.6%) and stage III and IV in 11 (7.3%) cases. On comparing the granuloma and non-granuloma cases histological features, it was found that fatty changes and inflammation were more with granuloma formation but there was no difference in the degree of fibrosis in the two groups. CONCLUSION: Liver involvement was mainly in the form of secondary tuberculosis. On histopathology, epitheloid cell granulomas were seen in 42% cases, other changes were non-specific. Significant fibrosis was seen in 7.3% cases however the finding of tuberculosis as a cause of significant fibrosis was not consistent.

Hepatic tuberculosis presenting as cholestatic jaundice. A case report.

We report three cases of hepatic tuberculosis with cholestatic jaundice. All three patients presented with cholestatic jaundice, anorexia, fever and weight loss. All had hepatomegaly. No biliary obstruction was detected. Two patients had evidence of extra hepatic tuberculosis but one had no such evidence. Diagnosis of hepatic tuberculosis was confirmed by liver biopsy. Little is known about tuberculous affecting the liver and the general belief is that it is a histopathological entity only, but these cases are a reminder of the unusual manifestation of a very common condition. All the cases recovered with anti-tuberculous treatment.

Abdominal wall abscess secondary to subcapsular tubercular liver abscess.

We report a 22-year-old woman who presented with an abdominal wall lump in the right upper quadrant 15 days after starting antitubercular treatment for right pleural effusion. CT scan revealed a right liver lobe subcapsular abscess communicating vith subcutaneous tissue. Aspiration of pus revealed acid-fast bacilli. She responded to 9 months of antitubercular treatment.

Disseminated tuberculosis presenting as hemobilia, successfully treated by arterial embolization.

Tuberculosis, specially disseminated tuberculosis, involves the liver frequently. Focal hepatic tuberculosis with local hemorrhage has been reported. We report on a twenty-one year female with disseminated tuberculosis presenting with initially non-localisable massive upper gastrointestinal bleeding, subsequently found to have pancreatitis, right sided pleural effusion and hemobilia which was treated successfully.

Hepatic artery mycotic aneurysm of tubercular aetiology.

Hepatic artery aneurysm caused by tuberculosis is extremely rare, the commonest being atherosclerosis and vasculitis. A 13 year boy admitted with suspected disseminated tuberculosis had a hepatic bruit. Patient died of aneurysmal rupture before antemortem etiological diagnosis could be established. Postmortem examination revealed widespread tubercular lesions in the chest and abdomen and hepatic artery aneurysm.

Tuberculous liver abscess.

Tuberculosis (TB) of liver is rare but may have a variety of presenting features similar to other more common conditions. A case of tuberculosis liver abscess with right sided pleural effusion is reported.

Granulomatous hepatitis: a retrospective study.

51 cases of granulomatous hepatitis were seen among 1234 liver biopsies over a 10 year period. Tuberculosis was the commonest cause seen in 55 percent of cases. Other causes included leprosy, sarcoidosis, histoplasmosis, brucellosis, amoebic liver abscess, lymphoma and malignant granuloma. 12 percent of cases remained undiagnosed. Clinically these patients presented with pyrexia and hepatosplenomegaly. Jaundice was uncommon. Many showed elevated alkaline phosphatase levels, anaemia and raised ESR Granulomatous hepatitis of unknown aetiology with FUO was seen in 6 percent cases only.

La ultrasonografía abdominal como método diagnóstico orientador en tuberculosis y/o micobacteriosis en pacientes H.I.V. / Abdominal tuberculosis in patients with AIDS: U.S. findings

Los pacientes HIV con tuberculosis y/o micobacteriosis se presentan en muchas oportunidades solamente como un síndrome febril. Nuestro objetivo fue evaluar la utilidad de la ultrasonografía abdominal en el diagnóstico de la patología micobacteriana asociada a la infección HIV. Se estudiaron 77 pacientes febriles con aislamiento previo o posterior al estudio de micobacterias (M. Tuberculosis: 74; atípicas: 3). Se utilizó equipo General Electric RT 4000, Transductor 3.5 MHz. Sectorial y lineal. Se realizó ecografía abdominal. Se realizó punción esplénica dirigida (2), punción hepática dirigida (12), punción psoas (1). Resultados: adenopatías retroperitoneales en 49 (64 por ciento); lesiones focales hipoecoicas (5-12 mm) en bazo 29 (38 por ciento), se punzaron 2 BAAR + Patrón hiperecogénico hepático en 39 (50,6 por ciento); lesiones focales hipoecoicas hepáticas en 2, se punzó 1 (Caseum); absceso hepático por M. Tuberculosis (1); acsitis en 21 (27 por ciento); absceso bilateral del psoas 2, se punzó 1 (BAAR +); trombosis vena esplénica 2; sin hallazgos ecográficos 10 (13 por ciento). El estudio demostró que las infecciones por micobacterias se pueden sospechar fuertemente ante un síndrome febril y presencia de adenopatías retroperitoneales (64 por ciento) y/o lesiones focales hipoecoicas de bazo (38 por ciento). Otros hallazgos como el patrón hiperecogénico se observó en un 57 por ciento. Se encontró una baja incidencia de lesiones focales hepáticas. La ecografía abdominal orienta en un 87 por ciento de los casos hacia el compromiso abdominal por micobacterias

Tuberculous abscess of the liver associated with HIV infection.

Tuberculosis is an AIDS-defining illness in HIV-seropositive patients. Though disseminated tuberculosis is common in HIV-seropositive patients, hepatic involvement in the form of abscess formation is rare. We report such a patient.