S3181 TB or Not TB? That Is the Question: A Case of Granulomatous Hepatitis

Abstract

Introduction: Granulomatous hepatitis is characterized by the presence of granulomas within the liver parenchyma. This disease has multiple etiologies with the most common being primary biliary cholangitis and sarcoidosis in the US, and tuberculosis (TB) worldwide. Despite TB being a leading cause of granulomatous hepatitis globally, it is exceedingly rare to have presentation of this disease isolated in the liver without the presence of pulmonary or disseminated infection. Increased awareness of this presentation, especially in HIV/AIDs patients can lead to a decrease in unnecessary testing and procedures as well as, efficient resource allocation. Case Description/Methods: A 53-year-old female with a history of HIV, not on antiretrovirals (ARVs), presented with fever for several days, and was found to be septic secondary to pneumonia. After resolution of her acute illness, she was restarted on ARVs, and was doing well until she developed fevers of unknown origin and transaminitis. Leading differential diagnosis included immune reconstitution inflammatory syndrome, drug-induced liver injury, and autoimmune hepatitis. Initial work-up revealed an elevated ANA and anti-smooth muscle antibody. However, given the low antibody titers and marginal improvement with steroids it was determined that an autoimmune etiology was unlikely. Additional workup led to a liver biopsy which was significant for necrotizing granulomas favored to be tuberculous over necrotizing sarcoidosis by pathology. Although the acid fast bacillus stain was negative, the patient was started on empiric therapy for TB given a high clinical suspicion, and she subsequently had a significant decrease in her transaminases. Discussion: The diagnosis of granulomatous hepatitis presents a challenge given the multiple etiologies of the disease. This difficulty is confounded in the setting of uncontrolled HIV/AIDs, especially when the underlying causes is from TB without pulmonary or disseminated TB infection. Diagnosis requires liver biopsy, with the initial analysis including direct microscopic visualization; and AFB staining. The problem that arose in this case is that tissue stains have a relatively low sensitivity of ∼72.7%, and ∼88% with PCR. It is important for providers to acknowledge that these diagnostic tests are not infallible, and the clinical context and medical history surrounding the patient can be the most important factor in clinical decision making when these test fail to yield the expected results.