Hepatic Tuberculosis: A Wolf in Sheep's Clothing

We thank Dr Semere for the keen interest in our article on granulomatous tubercular hepatitis presenting as haemophagocytic lymphohistiocytosis (HLH).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: 149-153https://doi.org/10.1016/j.jceh.2020.05.007Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar 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.2Desai C.S. Joshi A.G. Abraham P. et al.Hepatic tuberculosis in absence of disseminated abdominal tuberculosis.Ann Hepatol. 2006; 5: 41-43https://doi.org/10.1016/S1665-2681(19)32038-1Crossref PubMed Google Scholar 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.3Alvarez S.Z. Hepatobiliary tuberculosis.J Gastroenterol Hepatol. 1998; 13: 833-839https://doi.org/10.1111/j.1440-1746.1998.tb00743.xCrossref PubMed Scopus (99) Google Scholar Our patient had “granulomatous tubercular hepatitis” without the involvement of other organs by tuberculosis. Although our patient had multi-system involvement with ascites, pleural effusion and bicytopenia, we attributed these findings to the development of secondary HLH because we did not find evidence of tuberculosis in either ascitic or pleural fluid (low adenosine deaminase) or bone marrow. Computed tomography of the abdomen was not suggestive of tubercular involvement of the chest or abdomen. Also, the liver dysfunction, which was out of proportion to that seen normally with granulomatous tubercular hepatitis, may have been caused in part by secondary HLH. We agree that the differential diagnosis of granulomatous hepatitis includes sarcoidosis, opportunistic fungal infections, drug-induced granulomas, primary biliary cirrhosis and other granulomatous infections, but the presence of caseating granulomas with presence of acid-fast bacilli is very specific for tuberculosis, albeit with a low sensitivity of 0–35%.3Alvarez S.Z. Hepatobiliary tuberculosis.J Gastroenterol Hepatol. 1998; 13: 833-839https://doi.org/10.1111/j.1440-1746.1998.tb00743.xCrossref PubMed Scopus (99) Google Scholar Tuberculous involvement of the liver in light of its varied manifestations mimicking other diseases is truly a “wolf in sheep's clothing” with high mortality, particularly when accompanied by secondary HLH. Treatment entails judicious immunomodulation along with anti-tubercular therapy, although prospective data regarding therapy are lacking. Dr Shalimar. The authors have none to declare. Liver Involvement in Tuberculosis: A Polymorphic Disease With Protean ManifestationsJournal of Clinical and Experimental HepatologyVol. 11Issue 4PreviewWe 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.1 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). Full-Text PDF