The nodular form of hepatic tuberculosis: a review with five additional new cases

Abstract

Background: Tuberculosis presenting as an isolated liver tumour, without active pulmonary or miliary tuberculosis, or other clinical evidence of tuberculosis, is distinctly rare. A greater awareness of this rare clinical entity may prevent needless surgical intervention.

Aims: To help characterise this distinctly rare presentation of tuberculosis, five new cases are presented, together with a review of the world literature. The clinical, laboratory, radiological, and pathological features of these patients are described.

Methods: Polymerase chain reaction (PCR) assay of the liver tissue was carried out in all cases to confirm an aetiological diagnosis of Mycobacterium tuberculosis infection.

Results: All five patients (44-71 years old; two women, three men) underwent surgery, and had a preoperative diagnosis of malignant hepatic neoplasm and a postoperative histological diagnosis of chronic granulomatous inflammation, suggestive of tuberculosis. None of them had a known previous history of tuberculosis. All of them were positive for M tuberculosis by PCR analysis of the liver tissue.

Conclusions: This report illustrates the difficulty in reaching a correct preoperative diagnosis. It is usually unsuspected and confused with primary or metastatic carcinoma of the liver, especially when it coexists with other malignancies. A high index of suspicion is required for diagnosis, which can be made only by histological and bacteriological studies, and PCR analysis.

Figure 1

Abdominal computed tomography of case 1. A hypodense 13.0 × 8.0 × 7.0 cm mass in the left lobe of the liver with calcification.

Figure 2

The cut surface of the liver in patient 5. The liver revealed a solid, lobulated mass with yellow to tan discolouration, and central calcification.

Figure 3

Photomicrograph showing the histological findings in case 5. The conglomerate tubercle comprises Langerhans giant cells, epithelioid cells, and lymphocytes.

Figure 4

Polymerase chain reaction (PCR) analysis of all five cases. On electrophoresis of the PCR products a 123 bp DNA sequence (arrow), corresponding to the IS6110 insertion, was identified in the agarose gel. Lanes 1 to 5, cases 1 to 5, respectively; lane 6, normal liver; NC, negative control; PC, positive control.