Weight Loss in an Asian Man

Abstract

Question: A 28-year-old Filipino man, a known chronic hepatitis B carrier, presented with a 1-year history of significant weight loss. He did not have fever or cough, or any other systemic complaints. Physical examination was unremarkable. His blood results were: Protein, 98 g/L; albumin, 24 g/L; bilirubin, 21 μmol/L; alkaline phosphatase, 165 U/L; alanine aminotransferase, 433 U/L; aspartate aminotransferase, 394 U/L; alpha-fetoprotein, 117 μg/L; hemoglobin, 12.9 g/dL; white cell count, 5.61 × 109/L; platelets, 204 × 109/L; and erythrocyte sedimentation rate 103 mm/hr. Multiphasic contrast-enhanced computed tomography (CT) scan of the liver was performed (Figure A). Chest radiograph (not shown) was normal. What is the likely diagnosis from the CT scan? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Liver CT shows several centrally calcified nodular lesions in the right lobe with relatively low-density soft tissue surrounding them, best seen in the portal venous phase (Figure B,arrows). Similar lesions were present in the left lobe (not shown). There is no arterial enhancement or venous washout pattern to suggest multicentric hepatocellular carcinoma. The most likely cause of hypovascular infiltrative liver lesions with coarse nodular calcified foci are granulomatous infections, especially macronodular tuberculosis. Ultrasound-guided fine needle and core biopsy of the liver nodules was performed. Histopathologic analysis showed stromal fibrosis and chronic inflammation, residual bile ductular structures and epithelioid histiocytes (Figure C) Liver tissue culture grew Mycobacterium tuberculosis complex. Fungal culture was negative, as were serum cryptococcal, Histoplasma, and Treponema serologies. He was treated with a combination of 4 antituberculosis drugs for 2 months followed by 2 drugs for another 4 months. There was marked clinical improvement with return of his weight to baseline and normalization of liver function tests. There are 2 main radiologic manifestations of hepatic parenchymal tuberculosis.1Mortelé K.J. Segatto E. Ros P.R. The infected liver: radiologic-pathologic correlation.Radiographics. 2004; 24: 937-955Crossref PubMed Scopus (245) Google Scholar, 2Yu R.S. Zhang S.Z. Wu J.J. et al.Imaging diagnosis of 12 patients with hepatic tuberculosis.World J Gastroenterol. 2004; 10: 1639-1642Crossref PubMed Scopus (77) Google Scholar, 3Vanhoenacker F.M. De Backer A.I. Op de B.B. et al.Imaging of gastrointestinal and abdominal tuberculosis.Eur Radiol. 2004; 14: E103-E115PubMed Google Scholar Miliary hepatic involvement is seen in patients with miliary pulmonary tuberculosis and is characterized by innumerable tiny 0.5–2 mm nodules, which may sometimes be missed at CT, manifesting often as hepatomegaly only. Macronodular hepatic tuberculosis although less uncommon, is easily detected at CT and are typically low-density, hypovascular lesions measuring about 1–3 cm each and may show irregular, ill-defined margins. Tuberculomas eventually tend to calcify over time, and the presence of calcified granulomas at CT in the absence of a known primary malignancy should always raise suspicion for tuberculosis. Other granulomatous infections such as histoplasmosis typically occur in the setting of disseminated disease and presents with miliary sized lesions. Calcified metastases, typically from primary colorectal carcinoma, especially the mucinous histologic subtype, may also have this appearance, but this is highly unlikely in the given clinical context. This case also demonstrates the value of tissue culture over tissue staining in diagnosis of hepatic tuberculosis.