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Year : 2008  |  Volume : 51  |  Issue : 3  |  Page : 440-441
Isolated giant tuberculoma of the liver


Department of Pathology (Cardiovascular and Thoracic Division), Seth GS Medical College, Mumbai, India

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How to cite this article:
Vaideeswar P, Gupta R. Isolated giant tuberculoma of the liver. Indian J Pathol Microbiol 2008;51:440-1

How to cite this URL:
Vaideeswar P, Gupta R. Isolated giant tuberculoma of the liver. Indian J Pathol Microbiol [serial online] 2008 [cited 2019 Dec 14];51:440-1. Available from: http://www.ijpmonline.org/text.asp?2008/51/3/440/42556


A 22-year-old male was admitted in our Cardiovascular and Thoracic Center with a 2-year history of progressive dyspnea (grades II to III), palpitation and chest pain. A two-dimensional echocardiography revealed a patent ductus arteriosus (PDA, 0.8 cm diameter), an obstructive subaortic membrane, severe aortic regurgitation and left ventricular dysfunction. Other systemic examinations were normal; the liver was not palpable. Routine hematological and biochemical investigations were also within the normal range.

The patient was operated on the ninth day after admission; ligation of PDA, excision of sub-aortic membrane and aortic value replacement were performed. On the fourth post-operative day, the patient developed acute mediastinitis with a gaping infected sternotomy wound. Culture from the wound grew Klebsiella species. The patient was started on intravenous antibiotics, but his condition gradually deteriorated and he expired on the seventh post-operative day.

A complete autopsy was performed. At autopsy, remarkable features were seen in the liver. The liver weighed 1.5kg. There were multiple, rounded, confluent, gray-white raised areas, measuring 12 8 6 cm and extending over both the right and left lobes [Figure 1] and [Figure 2]. Histopathological study of the liver nodules showed extensive areas of caseation, surrounded by lymphocytes, epithelioid cells and Langhans giant cells [Figure 2]; many nodules also showed reactive fibrosis that infiltrated into the hepatic lobules. Surprisingly, there was no evidence of tuberculous inflammation in the porta hepatis lymph nodes, the intestines, mesenteric lymph nodes and even lungs. Acid-fast stains performed thrice on the paraffin sections were negative. Cytological preparations from the scrapings of the liver lesion revealed clumps of acid-fast bacilli [Figure 2]. Other findings at autopsy included a subdural hematoma over the left frontoparietal region, severe cardiomegaly (740 gm) with purulent pericarditis, severe concentric left ventricular hypertrophy, focal myocardial abscesses and normal aortic prosthesis. Death was as a result of septicemia.

Hepatic tuberculosis can manifest in one of the following patterns of involvement: as part of miliary (disseminated) tuberculosis, concomitant hepatic involvement with pulmonary tuberculosis, primary hepatic tuberculosis, tuberculoma or tuberculous abscess and tuberculous cholangitis.[1] Among these varied patterns, the liver is affected to the extent of 80% of patients with disseminated tuberculosis. [2] On the other hand, primary hepatic tuberculosis without lung involvement is quite uncommon and even rarer is the occurrence of primary hepatic tuberculoma, where multiple caseating granulomas form large tumor-like lesions in the liver. [2],[3],[4] Since 1995, about 25 cases of tuberculomas have been reported. [4]

Hepatic tuberculoma may produce the usual clinical signs and symptoms, related to a chronic inflammatory process along with tender hepatomegaly and elevated hepatic transaminases. [2] In a large percentage of cases, the hepatic tuberculoma is clinically silent and is only incidentally detected during imaging studies, exploratory laparotomy, or at autopsy (as in the present case). [2],[3],[4] It is therefore not surprising that when these uncommon entities occur in isolation, they are often misdiagnosed as primary or secondary hepatic tumors on imaging; the final diagnosis requires a biopsy confirmation. [2],[5] The frequency of positivity for acid-fast bacilli on tissue sections is not very high and even lower is the percentage of cultures which are positive for M. tuberculosis. [1] In our case, acid-fast staining failed to reveal the bacilli despite repeated attempts; the Mycobacteria were identified finally on scrape cytology. It has been suggested that the gastrointestinal tract is the primary source of infection in many hepatic tuberculomas. [2]

It is vital that the clinicians keep a diagnosis of hepatic tuberculoma in their mind when they detect space-occupying lesions in the liver of a patient, as the therapy is usually medical rather than surgical. The patients usually respond well to anti-tubercular chemotherapy alone; the prognosis of these patients has been found to be good. [3] Surgery is resorted to whenever unexpected complications arise. [6]

 
   References Top

1.Levine C. Primary macronodular hepatic tuberculosis: US and CT appearances. Gastrointest Radiol 1990;15:307-9.  Back to cited text no. 1  [PUBMED]  
2.Tan TC, Cheung AY, Lan WY, Chen TC. Tuberculoma of the liver presenting as a hyperechoic mass on ultrasound. Br J Radiol 1997;70:1293-5.  Back to cited text no. 2    
3.Culafic D, Boricic I, Vojinovic-Culafic V, Zdrnja M. Hepatic tuberculomas: A case report. Rom J Gastroenterol 2005;14:71-4.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Herman P, Pugliese V, Laurino Neto R, Machado MC, Pinotti HW. Nodular form of local hepatic tuberculosis: Case report. J Trop Med Hyg 1995;98:141-2.  Back to cited text no. 4  [PUBMED]  
5.Brookes MJ, Field M, Dawkins DM, Gearty J, Wilson P. Massive primary hepatic tuberculoma mimicking hepatocellular carcinoma in an immunocompetent host. Med Gen Med 2006;8:11.  Back to cited text no. 5    
6.Prochazka M, Vyhnanek F, Vorreith V, Jirasek M. Bleeding into solitary hepatic tuberculoma: Report of a case treated by resection. Acta Chir Scand 1986;152:73-5.  Back to cited text no. 6    

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Correspondence Address:
Pradeep Vaideeswar
Department of Pathology (Cardiovascular and Thoracic Division), Seth GS Medical College, Parel, Mumbai - 400 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.42556

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    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 Hepatobiliary tuberculosis
Chong, V.H., Lim, K.S.
Singapore Medical Journal. 2010; 51(9): 744-751
[Pubmed]
2 Liver tuberculoma
Treska, V., Hes, O., Nemcova, J.
Bratislava Medical Journal. 2009; 110(6): 363-365
[Pubmed]



 

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