Dual Portal Hypertension in Hepatic Tuberculosis: A Case Report

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Background: Hepatic tuberculosis in itself is a rare condition, and that causing portal hypertension is even rarer. We present a unique clinical scenario of portal hypertension in a 64-year-old woman, with tuberculosis causing both sinusoidal and prehepatic portal hypertension. Case Presentation: A 64-year-old woman presented with esophageal variceal bleeding. Evaluation revealed a rare combination of sinusoidal portal hypertension from hepatic tuberculosis and a prehepatic component of portal hypertension due to tubercular periportal lymphadenopathy compressing the portal vein at the hilum. Hepatic venous pressure gradient was 7 mm Hg, indicative of sinusoidal portal hypertension. Liver biopsy demonstrated bridging fibrosis and hepatic granulomas accounting for the sinusoidal component of portal hypertension. Since clinically significant portal hypertension is more than 10 mm Hg, variceal bleeding resulted from the additional element of prehepatic portal hypertension contributed by compression of extrahepatic portal vein by periportal lymph nodes. Positive tuberculosis polymerase chain reaction from lymph nodes confirmed the diagnosis and initiation of antitubercular therapy (ATT) led to significant clinical and biochemical improvement. This case represents a novel occurrence; hepatic tuberculosis causing both intrahepatic and prehepatic components of portal hypertension has not been reported in the literature. Conclusion: This case sheds light on the rarity of hepatic tuberculosis causing portal hypertension and also the importance of considering this diagnosis in patients with atypical presentations of tuberculosis. Recognizing and treating this unique complication promptly with ATT can lead to favorable clinical outcomes.