Massive Primary Hepatic Tuberculoma Mimicking Hepatocellular Carcinoma in an Immunocompetent Host

Matthew J. Brookes, MB ChB; Melanie Field, MB ChB; Dee M. Dawkins, MB ChB; Joan Gearty, MB ChB; Paul Wilson, MB ChB

Disclosures

July 18, 2006

Case Report

A 26-year-old Ugandan engineering student presented with a 5-month history of upper abdominal pain, dyspepsia, and weight loss. Clinical examination revealed epigastric and 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 178 mg/L), and an elevated alkaline phosphatase (153 IU/L).

He went on to have a transabdominal ultrasound, which demonstrated a 6.5-cm heterogenous mass in the left lobe of the liver with ultrasound features suggestive of hepatocellular carcinoma. Subsequent abdominal CT confirmed a mixed attenuation lesion measuring 6 x 5 cm, occupying most of the left lobe of the liver, and a smaller lesion in the right lobe (Figure 1) Multiple sub-1-cm lymph nodes were also found surrounding the small bowel mesentery. The appearances were suggestive of either lymphoma or hepatocellular carcinoma.

Contrast enhanced abdominal CT scan revealing a 6-cm by 5-cm mixed attenuating lesion in the left lobe, and a 4-cm lesion in the right lobe of the liver.

Serum tumor markers (alpha-fetoprotein, carcinoembryonic antigen, and CA 19-9) were negative, and a guided liver biopsy was performed. Histology revealed granulomatous inflammation associated with Langhans giant cells (Figure 2) suggesting mycobacterial infection. Aspiration of 100 mL of thick purulent material was performed under ultrasound guidance. Although Ziehl-Nielsen stain failed to demonstrate acid-fast bacilli, culture of the samples subsequently demonstrated the presence of Mycobacterium tuberculosis, sensitive to quadruple therapy. Plain chest radiology and thoracic CT revealed no evidence of pulmonary TB. Subsequent HIV serology was negative.

Histology revealing a granulomatous inflammation, little preservation of liver architecture, and presence of Langhans cells (arrow). (200× magnification, H and E stain)

The patient was commenced on ethambutol, isoniazid, pyrazinamide, and rifampicin. Within 3 months of therapy, the patient was asymptomatic with normal serum inflammatory markers. Repeat CT scan following 6 months of antituberculous therapy revealed a complete resolution of the lesion (Figure 3)

Contrast enhanced abdominal CT following 6 months of quadruple therapy, revealing a complete resolution of the lesions.

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