A Case of Hepatic Tuberculosis in a Patient with Acute Myelogenous Leukemia

Abstract

Purpose: Hepatic tuberculosis (HTB) usually occurs in the settings of pulmonary TB, but can exist without radiologic evidence of such. HTB may also be seen in the settings of TB mesenteric adenitis, since the mesenteric and hepatic lymph channels communicate. It may also develop via hematogenous spread by the hepatic artery or portal vein. HTB presents as miliary or localized form. Liver is commonly involved in miliary TB, but hepatic dysfunction is rare. Localized form is rare in the absence of pulmonary TB, probably due to low oxygen tension in the liver, which is unfavorable for mycobacterial growth. We report a case of localized HTB in a patient with acute myelogenous leukemia (AML), activated by chemotherapy. Methods: A 29 y/o man who immigrated from India 5 years ago was diagnosed with AML 7 months ago. He had no other past medical history, exposure to TB, or medication use. His PPD status was unknown. Baseline labs included hemoglobin 6.6 g/dl, wbc 1 K/mcL, platelets 59 K/mcL; liver function tests (LFT): albumin 3.5 g/dl, total bilirubin (TB) 0.5 mg/dl, alkaline phosphatase (ALP) 230 IU/L, AST 56 IU/L, ALT 118 IU/L. He received induction chemotherapy (Cytarabine, Daunorubicin), followed by worsening of LFT: TB 26 mg/dl, ALP 1359 IU/L, AST 366 IU/L, ALT 270 IU/L. Other etiologies for elevated LFT were excluded, including viral or autoimmune hepatitis or metabolic liver diseases. MRI/MRCP of the liver was normal. CT of chest showed mediastinal and hilar lymphadenopthy. Results: Liver biopsy revealed scattered microabscesses and non-caseating granulomas; mycobacteria were identified on acid fast stain. The repeat bone marrow biopsy revealed new non-caseating granulomas. Acid fast stain of sputum was positive for mycobacteria. Second line therapy with Rifampin, Ethambutol, Moxifloxacin and Amikacin was started. His LFT started to improve and normalized in 3 months. Conclusion: HTB has variable clinical presentation – the localized form is usually associated with more hepatocytic damage (high ALT), and the miliary form with more wasting (low albumin). Our case confirms the severe hepatocyte damage with localized form. This should increase the awareness of the potential clinical manifestations of HTB, particularly in patients from endemic areas or in immunocompromized ones.Figure. Acid: Fast Stain