Hepatic tuberculosis: a multimodality imaging review

Abstract

Objectives: We aim to illustrate the multimodal imaging spectrum of hepatic involvement in tuberculosis (TB). Whilst disseminated tuberculosis on imaging typically manifests as multiple small nodular lesions scattered in the liver parenchyma, isolated hepatic tuberculosis remains a rare and intriguing entity.

Methods: Indubitably, imaging is the mainstay for detection of tubercular hepatic lesions which display a broad spectrum of imaging manifestations on different modalities. While sonography and computed tomography (CT) findings have been described in some detail, there is a paucity of literature on magnetic resonance imaging (MRI) features. Due to a significant overlap with other commoner and similar appearing hepatic lesions, hepatic tuberculosis is often either misdiagnosed or labelled as indeterminate lesions. This article is a compendium of cases highlighting the spectrum of imaging patterns that can be encountered in patients with isolated primary hepatic tuberculosis as well as disseminated (secondary) disease. Rare patterns of primary disease such as tubercular cholangitis, hypervascular liver masses, and those with vascular complications are also illustrated and discussed.

Conclusions: Imaging plays a valuable role in the detection of tubercular hepatic lesions. Also, imaging can be helpful in their characterisation and for assessing associated complications.

Teaching points: • Hepatic TB has myriad imaging manifestations and is often confounded with neoplastic lesions. • Imaging patterns include miliary TB, macronodular TB, serohepatic TB and tubercular cholangitis. • Concurrent splenic, nodal or pulmonary involvements are helpful pointers towards the diagnosis. • Miliary calcifications along the bile ducts are characteristic of tubercular cholangitis. • Histological/microbiological confirmation is often necessary to confirm the diagnosis.

Keywords: CT; Hepatic tuberculosis; Miliary; Nodular; Tubercular cholangitis, MRI.

Fig. 1

A 46-year-old man with disseminated tuberculosis and elevated liver enzymes. a, b Ultrasound images show multiple hypoechoic lesions in the liver and spleen (arrows) in keeping with granulomas

Fig. 2

a Hepatic tuberculosis manifesting as hyperechoic liver lesions on ultrasonography (arrow). b One of the larger lesions shows central caseation and necrosis (dotted arrow)

Fig. 3

a Axial CT image of a 45-year-old woman with disseminated tuberculosis, showing multiple tiny hypodense lesions (thin arrows) in both lobes of the liver. b Disseminated disease in a 25-year-old man with multiple low attenuation cystic appearing lesions (short arrows) in the right lobe of the liver and associated ascites. c, d Contrast CT in a middle-aged woman with fever and disseminated tuberculosis exhibiting multiple hypodense lesions with subtle peripheral enhancement (dashed arrows)

Fig. 4

a Unenhanced CT of a 65-year-old woman with a history of weight loss showing retroperitoneal nodes with calcification (arrows). b, c Post-contrast CT images showing small hypodense lesions in both lobes of the liver (dashed arrows). Biopsy from the retroperitoneal nodes revealed metastases from mucinous adenocarcinoma

Fig. 5

a Axial contrast-enhanced CT of a 55-year-old woman with fever and weight loss exhibits multiple hypodense lesions (arrows) in the right lobe of the liver. Biopsy from the lesions revealed null cell lymphoma. b CT images of a 40-year-old man with known sarcoidosis shows subtle hypodense hepatic lesions (dashed arrows) with heterogeneous appearance of the spleen

Fig. 6

A middle-aged woman with a history of treated tuberculosis. a, b Axial contrast-enhanced CT images reveal multiple calcified lesions in the liver and spleen in keeping with calcified granulomas

Fig. 7

A 78-year-old man with weight loss and anorexia. a Ultrasound shows a well-defined hypoechoic lesion in the right lobe extending up to capsular surface (arrows). b, c Axial and coronal contrast-enhanced CT images show minimally enhancing subcapsular lesion in the right lobe (white dashed arrow) with associated capsular thickening (black dashed arrow)

Fig. 8

A 20-year-old man with fever. a Ultrasound shows a large, ill-defined heterogeneous lesion in the right lobe with relatively hypoechoic areas (arrows) suggestive of liquefaction. b, c Axial CT image in the portovenous phase shows the multiseptated peripherally enhancing lesion with septal enhancement and central necrosis (asterisk). Additionally, peritoneal thickening (dotted arrow) and infra-hepatic necrotic lymph nodal mass is noted (arrowhead). Patient underwent pigtail catheter drainage and culture and polymerase chain reaction (PCR) analysis revealed acid fast bacilli

Fig. 9

A 3-month-old child with failure to thrive. a Ultrasound shows a hypoechoic lesion in the right lobe with central hyperechoic area. b Portal venous phase CT reveals a small hypodense lesion in the right lobe with concurrent splenic lesions. c A large necrotic lymph node (asterisk) is also identified. d Histopathology from the hepatic lesion revealed a giant cell granuloma. This was a case of vertical transmission as mother was an active case of tuberculosis during pregnancy and delivery

Fig. 10

A 27-year-old man with fever, anorexia and isolated hepatic involvement. a Ultrasound shows an ill-defined heterogeneous area in the right lobe with a few well-defined hypoechoic areas (arrows) suggestive of liquefaction. b, c Arterial and portal venous phase reveals a well-circumscribed enhancing mass composed of multiple tiny abscesses. Vessels can be seen coursing through the lesion without being attenuated or infiltrated. d Magnified view shows tiny abscesses in a large complex mass giving a ‘cluster’ appearance

Fig. 11

a, b Plain CT images shows lesion with dense nodular calcification in the left lobe up to the interlobar fissure with concomitant multiple calcified lesions in spleen (arrows)

Fig. 12

A case of nodular isolated hepatic tuberculosis. Axial contrast-enhanced CT shows a well-defined lesion in the right lobe with thick enhancing rim (arrow) and central area of necrosis (asterisk)

Fig. 13

A 45-year-old man with right upper quadrant pain and fever. a, b Axial portal venous phase CT shows a hypodense lesion in the right lobe causing focal contour bulge and capsular thickening (arrow) with an associated organised collection in the perihepatic space (arrowhead). This was a patient with isolated hepatic tuberculosis with contained rupture of the tubercular liver abscess

Fig. 14

A 22-year-old man with features of hepatic failure. a Ultrasound shows a heterogeneously hypoechoic mass (arrows) in the right liver lobe. b Plain CT image shows dense calcification along the interlobar fissure with non-visualisation of the left lobe. c, d On arterial images, the lesion depicts arterial enhancement and central necrosis whilst it appears hypodense in the portal venous phase thus simulating a hepatocellular carcinoma. e Caudal sections reveal attenuated and thrombosed left portal branch (arrow) and normal appearing right and main portal branch. f Core biopsy specimen shows few hepatocytes and extensive caseous necrosis (asterisk)

Fig. 15

A 35-year-old man previously treated for pulmonary tuberculosis now presenting with elevated alkaline phosphatase. a, b Axial contrast-enhanced CT reveals chunky calcified nodular lesion in the segment VII of right lobe (arrow) with adjacent biliary radical dilatation (dotted arrow). b, c Axial T1- and T2-weighted MRI shows the corresponding lesion to be hypointense on T1 (thick arrow) and isointense to liver parenchyma on T2-weighted sequence. e, f Axial T2-weighted MRI reveals focal biliary radical dilatation (paired arrows), which is very well depicted on the MRCP image (short arrow)

Fig. 16

A 53-year-old man with fever and weight loss. a, b Axial contrast-enhanced CT showing peripherally located conglomerated hypodense lesions (white arrows) contiguously extending along the subcapsular plane of the right lobe, caudate lobe and on either side of the falciform ligament. The overlying thickened enhancing capsule simulates ‘sugar coating’. There is associated bulky necrotic gastrohepatic and retroperitoneal adenopathy (black arrows). c, d Low- and high-power miscroscopy reveal focally preserved liver tissue (arrowhead) intermixed with areas of caseous necrosis (asterisk)

Fig. 17

Coronal-oblique and coronal CT images in a patient with tubercular cholangitis displaying thickening and stricture of the extrahepatic common duct (arrows) with upstream intrahepatic biliary dilatation. The presence of hepatic calcifications (dotted arrows) help exclude cholangiocarcinoma and instead consider tuberculosis in appropriate clinical settings

Fig. 18

A 28-year-old man a known case of disseminated tuberculosis presenting with jaundice. a, b Ultrasound shows multiple areas of linear and miliary calcifications (arrow) in both lobes of liver. c Colour Doppler image shows dilated biliary radical with peripheral wall calcification. d Additionally, there is a well-defined small hypoechoic parenchymal lesion likely of a granuloma (short arrow)

Fig. 19

a, b Contrast-enhanced CT shows an ill-defined mass in the periportal location (short, thin arrows) with associated rather marked thickening of the extrahepatic common duct (short, thick arrow). Extensive calcifications can be seen along the biliary radicals (black arrows). c Concurrent hypodense liver lesions either granulomas or cholangitic abscesses (dotted arrows). d Associated large retroperitoneal nodal mass (asterisk) is visualised

Fig. 20

Axial T2-weighted MRI displaying an ill-defined heterogeneous area (short arrows) in the right lobe of liver corresponding to granulomatous infiltration, which extends into the periportal location, resulting in central biliary radical dilatation (dotted arrows) with concurrent multiple hypointense splenic nodules (arrows) in a patient with hepatobiliary tuberculosis

Fig. 21

A 21-year-old young woman a known case of disseminated tuberculosis with obstructive jaundice. a, b Axial T1- and T2-weighted MRI display dilated biliary tree (arrow) with a non-necrotic nodal mass at the hepatic hilum (long arrow). c Axial T2-weighted MRI reveals a smaller node (dotted arrow) along the central bile duct (CBD; arrow), which is dilated. d Post-contrast T1-weighted image shows mild enhancement in the node as well as along the walls of the CBD. e, f Coronal T2-weighted MRI and thick-slab 3D MRCP beautifully delineates the tight narrowing of the mid extrahepatic common duct in this patient