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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Pseudotumoral Hepatic Tuberculosis: A Rare Variant Masquerading as Multifocal Liver Malignancy
Pseudotumoral Hepatic Tuberculosis: A Rare Variant Masquerading as Multifocal Liver Malignancy
Contributed by : Sarthak Rathi
Contributed by : Sarthak Rathi
Introduction :
Introduction :
Hepatic tuberculosis is an uncommon manifestation of extrapulmonary tuberculosis and may occur as part of disseminated disease or, rarely, as isolated hepatic involvement. The liver may be involved through hematogenous dissemination, lymphatic spread or direct extension from adjacent structures.
Hepatic tuberculosis is an uncommon manifestation of extrapulmonary tuberculosis and may occur as part of disseminated disease or, rarely, as isolated hepatic involvement. The liver may be involved through hematogenous dissemination, lymphatic spread or direct extension from adjacent structures.
Case presentation :
Case presentation :
A 25 year old woman presented with complaints intermittent low grade fever for three weeks, reduced appetite, generalized weakness, unintentional weight loss and dull, non radiating pain in the right hypochondrium for two weeks.
A 25 year old woman presented with complaints intermittent low grade fever for three weeks, reduced appetite, generalized weakness, unintentional weight loss and dull, non radiating pain in the right hypochondrium for two weeks.
There was no history of jaundice, vomiting, or significant alteration in bowel habits.
There was no history of jaundice, vomiting, or significant alteration in bowel habits.
On examination, the patient was febrile and mildly pale. Mild, hepatomegaly was present. No clinically palpable peripheral lymphadenopathy was noted.
On examination, the patient was febrile and mildly pale. Mild, hepatomegaly was present. No clinically palpable peripheral lymphadenopathy was noted.
Laboratory investigations revealed mild anemia, mild elevation of alkaline phosphatase, mild increase in transaminase levels and elevated ESR. Total bilirubin was within normal limits.
Laboratory investigations revealed mild anemia, mild elevation of alkaline phosphatase, mild increase in transaminase levels and elevated ESR. Total bilirubin was within normal limits.
Radiological Findings :
Radiological Findings :
Ultrasonography (Figure 1)
Ultrasonography (Figure 1)
Ultrasonography of the abdomen demonstrated multiple, well defined, heterogeneously hyperechoic lesion 3x2.2cm in size with hypoechoic wall in the left lobe of the liver. There was no internal vascularity or calcifications.
Ultrasonography of the abdomen demonstrated multiple, well defined, heterogeneously hyperechoic lesion 3x2.2cm in size with hypoechoic wall in the left lobe of the liver. There was no internal vascularity or calcifications.
The multiplicity of lesions initially raised the possibility of metastatic disease or multifocal hepatic infection.
The multiplicity of lesions initially raised the possibility of metastatic disease or multifocal hepatic infection.
Fig 1
Figure 1. Ultrasonography: There is a well defined, heterogeneously hyperechoic lesion (black arrow) 3x2.2cm in size with hypoechoic wall in the left lobe of the liver. There is no vascularity or calcification.
Contrast-enhanced CT abdomen (Triple Phase) ( Figure 2a & 2b)
Contrast-enhanced CT abdomen (Triple Phase) ( Figure 2a & 2b)
There was an ill-defined, hypodense lesion measuring 2x5.6x2.8cm with multiple enhancing septate in the left lobe of liver. There were multiple linear serpiginous hypodensities along the biliary radicals in the peripheral part of the right lobe of the liver.
There was an ill-defined, hypodense lesion measuring 2x5.6x2.8cm with multiple enhancing septate in the left lobe of liver. There were multiple linear serpiginous hypodensities along the biliary radicals in the peripheral part of the right lobe of the liver.
Figure 2 a,b
Figure 2a. Axial contrast-enhanced CT image shows an ill defined, hypodense lesion ( black arrow) measuring 2x5.6x2.8cm with multiple enhancing sepate in the left lobe of liver.
Figure 2b. Axial contrast-enhanced CT image shows multiple linear serpiginous hyposensities (black arrow) along the biliary radicals in the peripheral part of right lobe of the liver.
Contranst enhanced MRI Abdomen (Figure 3a, 3b and 3c)
Contranst enhanced MRI Abdomen (Figure 3a, 3b and 3c)
There were well-defined, intercommunicating, irregular marginated, thick walled, peripherally enhancing T2/STIR hyperintense collections showing diffusion restriction and corresponding drop in ADC in segment IV A with largest pocket measuring 23x18x10mm (AP x TR x CC). No communication with adjacent bile ducts was noted. There were few serpiginous tracts in segment VIII of liver with maximum width measuring 3.3mm. One of the tracts measuring 13x12mm, terminated into the well-defined collection in segment IV B,
There were well-defined, intercommunicating, irregular marginated, thick walled, peripherally enhancing T2/STIR hyperintense collections showing diffusion restriction and corresponding drop in ADC in segment IV A with largest pocket measuring 23x18x10mm (AP x TR x CC). No communication with adjacent bile ducts was noted. There were few serpiginous tracts in segment VIII of liver with maximum width measuring 3.3mm. One of the tracts measuring 13x12mm, terminated into the well-defined collection in segment IV B,
Figure 3a , 3b and 3c.
Axial contrast-enhanced CT image shows well-defined, intercommunicating , rregular marginated , thick walled peripherally enhancing, T2/STIR hyperintensity collections (Figure 3a, black arrow) . This shows diffusion restriction (Figure 3b) and corresponding drop in ADC (Figure 3c) in segment IV A with largest pocket measuring 23x18x10 mm it's so There is no communication with adjacent bile ducts. There are few serpiginous tracts in segment VIII.
Radiological Diagnosis :
Radiological Diagnosis :
Differential Diagnosis:
Differential Diagnosis:
1. Pyogenic liver abscess
1. Pyogenic liver abscess
Peripheral enhancement and central necrosis may mimic abscesses. However, the relatively small, multiple lesions associated with splenic granulomas and necrotic lymphadenopathy are more suggestive of granulomatous infection.
Peripheral enhancement and central necrosis may mimic abscesses. However, the relatively small, multiple lesions associated with splenic granulomas and necrotic lymphadenopathy are more suggestive of granulomatous infection.
2. Hepatic tuberculosis
2. Hepatic tuberculosis
Given the multiple hypodense hepatic lesions with peripheral/rim enhancement and central necrosis/caseation along with constitutional symptoms indicated likely diagnosis.
Given the multiple hypodense hepatic lesions with peripheral/rim enhancement and central necrosis/caseation along with constitutional symptoms indicated likely diagnosis.
3. Metastatic disease
3. Metastatic disease
Multiple hepatic lesions are commonly encountered in metastatic disease. However, the absence of a demonstrable primary tumor and the presence of necrotic lymph nodes and splenic lesions in this clinical setting made metastases less likely.
Multiple hepatic lesions are commonly encountered in metastatic disease. However, the absence of a demonstrable primary tumor and the presence of necrotic lymph nodes and splenic lesions in this clinical setting made metastases less likely.
4. Biliary hamartomas
4. Biliary hamartomas
Biliary hamartomas are multiple variable-sized, anechoic cystic lesions in liver parenchyma without communication with the biliary system.
Biliary hamartomas are multiple variable-sized, anechoic cystic lesions in liver parenchyma without communication with the biliary system.
5. Lymphoma
5. Lymphoma
Lymphoma may produce multiple hypodense hepatic lesions and lymphadenopathy. However, the characteristic central necrosis of lymph nodes is less typical in untreated lymphoma .
Lymphoma may produce multiple hypodense hepatic lesions and lymphadenopathy. However, the characteristic central necrosis of lymph nodes is less typical in untreated lymphoma .
Pathological Diagnosis :
Pathological Diagnosis :
Ultrasound-guided core biopsy of one of the serpiginous hypodense lesions in the right lobe of the liver was performed.
Ultrasound-guided core biopsy of one of the serpiginous hypodense lesions in the right lobe of the liver was performed.
Histopathological examination demonstrated multiple epithelioid cell granulomas with central caseous necrosis with surrounding chronic inflammatory cell infiltrate.
Histopathological examination demonstrated multiple epithelioid cell granulomas with central caseous necrosis with surrounding chronic inflammatory cell infiltrate.
The overall findings were consistent with tuberculous granulomatous inflammation.
The overall findings were consistent with tuberculous granulomatous inflammation.
Histological demonstration of caseating granulomas and/or microbiological confirmation is often required because hepatic TB can closely mimic malignancy on imaging.
Histological demonstration of caseating granulomas and/or microbiological confirmation is often required because hepatic TB can closely mimic malignancy on imaging.
Final diagnosis : Hepatic tuberculosis
Final diagnosis : Hepatic tuberculosis
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