TB of Porta Hepatis Presenting With Obstructive Jaundice: A Case Report

Abstract

Introduction: Mycobacterium Tuberculosis causes tuberculosis. The number of reported TB cases in United States has been decreasing each year in the last 2 decades. Extra pulmonary TB can present anywhere in the body, however isolated peri-pancreatic or hepatobiliary TB is rare. Case Report: 25-year-old Pakistani immigrant male presented with 2 weeks of vague RUQ pain, pruritus, fever, nausea, acolic stool and dark urine. On exam: RUQ abdominal tenderness, yellow skin discoloration. AST 107 IU/L, ALT 211 IU/L, ALP 273 IU/L, LDH 214 IU/L, total bilirubin 11.4 mg/dl, indirect bilirubin 4 mg/dl, direct bilirubin 7.4 mg/dl. US showed a mass in the pancreatic area. CT showed a 5.5x4.1x4.8 cm complex cystic mass in the region of Porta Hepatis with resultant intrahepatic biliary dilatation that extends to the level of mass as well as 1.4 cm intra-aortocaval lymph node. Emergency ERCP with biliary stent placement was performed. FNA of the intra-aortocaval lymph node was performed. Biopsy: granulomatous inflammation, negative for malignant cells, fungal or AFB stains; the PCR positive for M. Tuberculosis DNA. CT chest: bulky non-calcified right Para-tracheal lymph node (1.5x2.7 cm). Mediastinoscopy was performed with lymph node biopsy: granulomatous inflammation, stains for AFB and fungi negative, PCR positive for M.Tuberculosis. T spot TB test was positive. Patient improved with stent placement and started on Isoniazid, Rifampin, Pyrazinamide and Ethambutol (2 months), followed by INH and Rifampin (4 months). Follow up imaging: complete resolution of the porta hepatis mass and lymph nodes. Discussion; Abdominal TB presents in one or more of the following forms: tuberculous lymphadenopathy, peritoneal tuberculosis, GI tract tuberculosis and visceral tuberculosis. Abdominal TB can occur due to hematogenous route, inhaling the tuberculosis spores, tubercular focus can develop in the lung from which hematogenous spread to other body parts takes place or ingestion of bacteria and then translocation across the intestinal wall. Diagnosis is made by demonstration of granulomas or AFB on Zeil-Neelson stain (low diagnostic value). PCR can effectively detect mycobacterium DNA in tissue sample. Early treatment with Quadruple therapy can effectively treat abdominal TB. Conclusion: Porta hepatis TB diagnosis is challenging and often confused with malignancy with high mortality risk if left untreated. Clinical outcome improves significantly with anti-Tuberculosis drugs.Figure: CT Abdomen, axial section, showing mass in porta hepatis area.Figure: CT abdomen, coronal section, showing mass in porta hepatis area with resultant intrahepatic biliary dilatation.Figure: CT abdomen, axial section, showing CBD stent with resolution of porta hepatis mass.