Liver Involvement in Tuberculosis: A Polymorphic Disease With Protean Manifestations

We read with great interest the fascinating manuscript by Elhence et al describing a case of granulomatous tubercular hepatitis associated with hemophagocytic lymphohistiocytosis (HLH), successfully managed with a combination of immunosuppressants and antitubercular therapy.1Elhence A. Aggarwal A. Goel A. Aggarwal M. Das P. Shalimar Granulomatous tubercular hepatitis presenting as secondary hemophagocytic lymphohistiocytosis: a case report and systematic review of the literature.J Clin Exp Hepatol. 2021; 11: 149-153Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar They also present a systematic review of tuberculosis-associated HLH (TB-HLH) literature as a rare clinical entity. Although we find this case very interesting and of clinical relevance, we would like to add a comment that we consider relevant on the hepatic involvement of tuberculosis (TB). As correctly stated by the authors, most cases of TB-HLH described in the literature have extrapulmonary TB and disseminated tuberculosis.2Brastianos P.K. Swanson J.W. Torbenson M. Sperati J. Karakousis P.C. Tuberculosis-associated haemophagocytic syndrome.Lancet Infect Dis. 2006; 6: 447-454Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar,3Anand A.C. Garg H.K. Approach to clinical syndrome of jaundice and encephalopathy in tropics.J Clin Exp Hepatol. 2015; 5: S116-S130Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar In contrast, the case described by Elhence et al had evidence of granulomatous tuberculous hepatitis and no evidence of TB elsewhere. Extrapulmonary TB represented 15% of the 7.0 million incidental cases notified in 2018, ranging from 8% in the Western Pacific Region to 24% in the Eastern Mediterranean Region. In northern Europe and the USA, up to 40% of all TB cases are extrapulmonary, and lymphadenitis is the most common extrapulmonary presentation.4reportGlobal Tuberculosis Report. 2018. Available online: https://www.who.int/tb/publications/global_report/gtbr2018_main_text_12August2019.pdf?ua=1.Google Scholar Hepatic TB is almost invariably associated with systemic dissemination of TB bacilli and is often unrecognized because of its relatively nonspecific clinical presentations. In this regard, we thought it relevant to mention that hepatic involvement in TB can have various clinical-imaging manifestations. Hepatic involvement in TB is insidious because, just as in HLH, the clinical manifestations may be nonspecific, and the diagnosis may be difficult as, in some cases, it may be misdiagnosed. The differential diagnosis of hepatic miliary TB includes sarcoidosis, opportunistic fungal infections, metastasis, lymphoma, or other granulomatous diseases.5Karaosmanoglu A.D. Onur M.R. Sahani D.V. Tabari A. Karcaaltincaba M. Hepatobiliary tuberculosis: imaging findings.Am J Roentgenol. 2016; 207: 1-11Crossref PubMed Scopus (14) Google Scholar, 6Yu R.S. Zhang S.Z. Wu J.J. Li R.F. Imaging diagnosis of 12 patients with hepatic tuberculosis.World J Gastroenterol. 2004; 10: 1639-1642Crossref PubMed Scopus (75) Google Scholar, 7Tsui W.M. Wong K.F. Tse C.C. Liver changes in reactive haemophagocytic syndrome.Liver. 1992; 12: 363-367Crossref PubMed Scopus (31) Google Scholar, 8Forgione A. Tovoli F. Ravaioli F. et al.Contrast ultrasound LI-RADS LR-5 in hepatic tuberculosis: case report and literature review of imaging features.Gastroenterol Insights. 2020; : 1-9Google Scholar Therefore, in light of the Elhence data, we suggest that granulomatous TB hepatitis associated with secondary HLH should be taken into account among the potential clinical manifestations of hepatic TB. Linda Beenet. Gebrehiwet Semere: Conceptualization, Methodology, Data curation, Writing – original draft, Writing - review & editing. The author has none to declare. Hepatic Tuberculosis: A Wolf in Sheep's ClothingJournal of Clinical and Experimental HepatologyVol. 11Issue 4PreviewWe thank Dr Semere for the keen interest in our article on granulomatous tubercular hepatitis presenting as haemophagocytic lymphohistiocytosis (HLH).1 We agree that isolated hepatic tuberculosis is a rare manifestation of extrapulmonary tuberculosis, but the presence of isolated hepatic tuberculosis without evidence of tuberculosis elsewhere has been described in the literature.2 Also, hepatic tuberculosis is not always innocuous or insidious, as suggested. Alvarez had classified hepatic involvement in tuberculosis based on its clinical features into 1) miliary form: characterised by disseminated tuberculosis and no symptoms of liver involvement, 2) granulomatous tubercular hepatitis: characterised by unexplained fever, jaundice and mildly elevated liver enzymes and presence of caseating granulomas in the liver and 3) localised hepatic tuberculosis: characterised by localised involvement of the liver in the form of a nodule, pseudotumor or abscess, with or without the involvement of the biliary system. Full-Text PDF