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HEPATIC TUBERCULOSIS
A Sharma*, P Madhok**
*Ex-Registrar; **Hon. Paediatric Surgeon, Jerbai Wadia Children's Hospital, Parel, Mumbai 12.
This communication, reports an unusual presentation of Hepatic Tuberculosis. Clinical presentation was that of a large space occupying lesion in the liver, which at laparotomy and histological examination revealed a tubercular granuloma of the liver. The relevant literature has been briefly reviewed.INTRODUCTION
Inspite of advances in treatment, tuberculosis remains a health problem in our country. Abdominal tuberculosis ranks second, after pulmonary Th in children, and involves the intestine, mesenteric glands and peritoneum. Liver involvement is uncommon and when it occurs it takes the form of miliary tubercles. Tuberculous granulomas are extremely rare especially in children and must be distinguished from other space occupying lesions in the liver particularly malignancy. Imaging techniques help, but a tissue diagnosis is mandatory. This is best done at open laparotomy, which not only enables the surgeon to size up the problems and take a biopsy, but also helps to clear the granulation tissue and septic material.
CASE REPORT
A 10 year old Mohammedan male child presented with a history of low grade fever for 6 months and gradually increasing upper abdominal distension for 3 months. On examination, the liver was palpable 4 fingers below the right subcostal margin, nodular, firm and non tender. Spleen was palpable 2 fingers below the left subcostal margin. Investigations revealed Hb 8.1 gm% WBC count 23,00 c/min and ESR 104 mm at I hour LIFT (Liver function tests) normal. Serum AFP (Alpha foeto protein) levels and urinary VMA (Venyl Mandelic Acid) levels were normal. A plain X-ray revealed calcification, in the hepatic area. USG
(Ultrasonography) reported multiple hypoechogenic areas in liver parenchyma, with enlarged paracaval, paraaortic and parapancreatic nodes. Liver scan showed large, irregular, cold areas in right lobe of liver. On percutaneous liver biopsy pallisaded epitheloid cells with a few well formed granulomas were visualised with a tentative diagnosis of "walled off tuberculoma".
A right paramedian laparotomy was performed. Ascites was present. Right lobe of liver was studded with multiple nodules of 2-4 cm diameter. These were deroofed and whitish caseous tissue scooped. Many small nodules were similarly scooped open and biopsy taken. Spleen was enlarged, but no tubercles were present. There were no strictures or seedlings in the intestines. Mesenteric glands were enlarged from which biopsy was taken. The histopathological report was tubercular granuloma of the liver and acute necrotising lymphadenitis (consistent with tuberculosis) of the mesenteric glands.
The patient was put on rifampicin, INH, ethambutol, which were given for a total period of I year. After a year, the liver and spleen were not palpable and there was a marked improvement in general condition and weight. A repeat USG reported marked reduction in size of lesions.
DISCUSSION
May Robson was the first to present a case of hepatic tuberculosis, in 1895. Subsequently till 1938, Mayo Clinic could collect only 14 patients, mostly individual case reports. Ashton [1] conducted 180 post mortems in a TB sanatorium in Africa, and concluded that miliary was the commonest form of hepatic involvement. Leader (1952) analysed 80 hepatic abscesses and considered 2 of them of tubercular origin. Udani [4] considered 9% hepatically involved in a series of 100 post mortems on tuberculous children. Zipser [5] reported a case of hepatic pseudo tumour of tubercular origin, successfully treated by drainage.
Payling Wright working on an experimental model drew attention to the lymphatic route as the most likely source of hepatic infection. A previous insult like chemical or viral infective damage served as predisposing cause.
In this case, laparotomy revealed mesenteric involvement, but the intestines did not reveal tubercle. Granulornatous lesions indicate a high degree of immunity, and we are apt to see hyperplastic type of tuberculosis only in older children. Desai et al [2] have reported 12 cases of hepatic tuberculosis presenting as PUO and have advocated laparoscopic biopsy. Kapoor reported a case of solid tuberculoma [3] in the adult liver and suggested surgical excision, if medical treatment failed.
Although percutaneous biopsy indicated tuberculosis, in view of the rarity of hepatic involvement a laparotomy was considered necessary. (And the high level of suspicion of malignancy). This provided a good opportunity to study the extent of involvement and to deroof the abscesses and scoop out the granulation tissue. This may have helped an early recovery. One looks forward to the day when this will be possible through the laparoscope.
REFERENCE
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