Features and Outcome of Hepatobiliary Tuberculosis among Filipino Children: Report of a Six-year Experience

Background@#The features and outcome of hepatobiliary tuberculosis (HBTB) have not been extensively reported in children.@*Objective@#To describe the clinical, biochemical, radiologic, microbiologic and histologic features and outcome of children diagnosed with HBTB. @*Methods@#Data of HBTB patients aged 0-18 years were collected by review of medical records and as they were admitted. Cases were classified as bacteriologically-confirmed (positive AFB smear, TB culture or PCR of bile/liver tissue) or clinically-diagnosed (clinical, histologic and/or radiologic evidence). @*Results@#A total of 36 patients were included (mean age: 13yrs; 64% males): three bacteriologically-confirmed and 33 clinically-diagnosed. Most common signs/symptoms were weight loss (69%), fever (67%), hepatomegaly (61%) and jaundice (53%). Of the total, 68% had hypoalbuminemia, 50% increased transaminases and 47% prolonged prothrombin time. Fifteen (42%) patients were AFB positive on various microbiologic specimens. Most common imaging finding was hepatic calcification (64%). Of 11 patients with liver biopsy, seven (64%) had chronic/ granulomatous inflammation. All 36 were managed medically. Eight were lost to follow up, six died, and 22 (61%) are alive, nine with complete resolution of liver disease. @*Conclusion@#Hepatobiliary tuberculosis presents with non-specific clinical and biochemical findings. Several investigations are necessary to confirm the diagnosis. Overall response to anti-TB treatment is satisfactory with possible resolution of liver disease.

Enfermedad granulomatosa hepática / Hepatic granulomatous disease

Resumen Los granulomas son lesiones circunscritas compuestas principalmente por células mononucleares que surgen en respuesta a estímulos antigénicos pobremente degradables. Se encuentran en 2 a 15 % de las biopsias hepáticas; su hallazgo puede significar desde un fenómeno incidental, hasta la manifestación de una enfermedad sistémica de origen infeccioso, autoinmune o neoplásico. El cuadro clínico suele apuntar a la patología subyacente, sin embargo, la lista de condiciones asociadas es amplia y difiere con base en los antecedentes epidemiológicos y a las características basales del paciente. El elemento de mayor utilidad para su estudio es la historia clínica exhaustiva, con énfasis en viajes recientes, exposición de riesgo y consumo de fármacos o alimentos crudos o exóticos. El análisis histopatológico detallado puede auxiliar en la identificación de la etiología, por ejemplo, la presencia de granulomas epitelioides con necrosis caseosa indica tuberculosis y su ausencia, sarcoidosis; la abundancia de eosinófilos es señal de reacciones farmacológicas o infecciones parasitarias; la presencia de cuerpos extraños puede ser la causa de la enfermedad granulomatosa hepática. En este artículo describimos los aspectos clínico-patológicos básicos de esta enfermedad y proveemos un breve resumen de las etiologías más comunes, principalmente en la región de Latinoamérica.

Abstract Granulomas are circumscribed lesions mainly composed of mononuclear cells that arise in response to poorly degradable antigenic stimuli. They are found in 2-15 % of liver biopsies and the meaning of their finding can range from an incidental phenomenon to the manifestation of a systemic disease of infectious, autoimmune or neoplastic origin. Clinical presentation usually points at the underlying pathology; however, the list of associated conditions is extensive, and differs based on patient epidemiological history and baseline characteristics. The most useful element for their study is a thorough medical history, with an emphasis on recent trips, exposures and consumption of drugs or raw or exotic foods. Detailed histopathological analysis may help identify the etiology. For example, the presence of epithelioid granulomas with caseous necrosis indicates tuberculosis and, its absence, sarcoidosis; eosinophil abundance can be associated with drug reactions or parasitic infections; and the presence of foreign bodies can be the cause of granulomatous liver disease (GLD). In this article, we describe the basic clinical-pathological aspects of GLD, and provide a brief summary of the most common etiologies, with an emphasis on the Latin-American region.

Hepatic granulomas in canine visceral leishmaniasis and clinical status

The histopathological description of intralobular hepatic granulomas in animals with a defined clinical status (asymptomatic, oligosymptomatic and symptomatic animals) was reported. Seventy-one mongrel dogs naturally infected with Leishmania chagasi were obtained from two Brazilian endemic areas: João Pessoa, PB and Belo Horizonte, MG. The hepatic parasite load was determined and compared to granuloma formation. Liver fragments from all infected animals showed remarkable leishmaniotic granulomatous inflammatory reaction. Granulomas with variable size were constituted by macrophages (parasitized or not with amastigotes of L. chagasi), some epithelioid cells, small numbers of lymphocytes, plasma cells, and rare neutrophils. Asymptomatic dogs had higher numbers of granulomas than oligosymptomatic and symptomatic animals from both geographical regions. However, the average diametric size of granulomas was very heterogeneous in all groups, independently of the geographic region (P>0.05). Parasite tissue load did not show any difference among liver fragments of all animals, especially when considering the defined clinical status and/or their geographic origin

Descreve-se a formação de granulomas hepáticos na leishmaniose canina em animais com classificação clínica definida - assintomáticos, oligossintomáticos e sintomáticos. Setenta e um animais, sem raça definida e naturalmente infectados com Leishmania chagasi, foram obtidos de duas regiões endêmicas brasileiras: João Pessoa, PB e Belo Horizonte, MG. A carga parasitária tecidual foi determinada mediante emprego do Leishmania Donovani Units (LDU) e comparada com a formação de granulomas hepáticos. Fragmentos de fígado de todos os animais infectados mostraram reação granulomatosa notadamente leishmaniótica. Granulomas de variáveis tamanhos eram constituídos por macrófagos, parasitados ou não com formas amastigotas de L. chagasi, algumas células epitelióides, pequeno número de linfócitos e plasmócitos, e raros neutrófilos. Cães assintomáticos apresentaram maior número de granulomas do que os animais oligossintomáticos e sintomáticos, em ambas as regiões geográficas. As médias dos diâmetros foram heterogêneas em todos os grupos, independente da região geográfica (P>0,05). Quanto ao parasitismo (LDU), não houve diferença entre as amostras de fígado, especialmente quando se consideraram a classificação clínica e a região geográfica

A Case of Sarcoidosis with Cavitation / 결핵및호흡기질환

Sarcoidosis is a rare systemic disorder with unknown cause that is characterized pathologically by non-caseating granuloma. The lung and mediastinal lymph nodes are almost always involved, and most patients experience acute or insidious respiratory symptom. Because sarcoidosis is an interstitial lung disorder involving the alveoli and bronchioles, the most common radiological finding is a reticularnodular lesion with lymphatic distribution. However, cavitation is quite rare. Sarcoidosis is also a major cause of hepatic granuloma in Western countries, accounting for 12% to 30% of cases. In most patients, the course of hepatic sarcoidosis is benign. However, chronic intrahepatic cholestasis or portal hypertension may develop in some patients. We report a case of sarcoidosis with cavitation and hepatic involvement.

Eosinophilic Liver Abscess in Patients with Gastric Carcinoma

Sixteen cases of heavy eosinophil infiltration or eosinophilic abscess of the liver in patients with gastric carcinoma were analyzed to draw attention to this interesting combination and to persue the pathogenetic mechanism. Peripheral blood eosinophilia and hepatic granuloma were found in only 5 and 4 cases, respectively. Neither the patients' stool nor the hepatic tissues disclosed any parasitic worms or eggs, although the skin tests for Clonorchis sinensis and Paragonimus westermani were positive in 2 cases. Among stomach carcinomas, early gastric cancer tended to have more eosinophils than advanced carcinoma, but was less frequently associated with the infiltration of mast cells. In the regional lymph nodes, there was no infiltration of eosinophils even in the presence of tumor metastasis. In the liver, none of the 16 cases had metastatic gastric carcinoma and mast cells were found in only 2 cases. The results suggest that heavy hepatic infiltration of eosinophils in gastric carcinoma patients is not of the parasitic or allergic cause, but of certain eosinophil chemotactic factor which may gain access to accumulate in the liver following released from the gastric carcinoma and transfered through the portal vein.