Nodular Hepatic Tuberculosis about a Case: An Underestimated Diagnosis

Case Report

J Bacteriol Mycol. 2021; 8(6): 1189.

Nodular Hepatic Tuberculosis about a Case: An Underestimated Diagnosis

Benaissa E1*, Elbnaissi Y2, Reggad A2, Oucharqui S1, Bssaibis F1, Jidane S3, Maleb A4, Belyamani L3, Ennibi K2 and Elouenness M1

1Department of Bacteriology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy (University Mohammed V), Rabat, Morocco

2Center for Virology, Infectious and Tropical Diseases, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy (University Mohammed V), Rabat, Morocco

3Emergency Department, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy (University Mohammed V), Rabat, Morocco

4Laboratory of Microbiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy (University Mohammed the first), Oujda, Morocco

*Corresponding author: Elmostafa Benaissa, Department of Bacteriology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy (University Mohammed V), Rabat, Morocco

Received: October 07, 2021; Accepted: November 01, 2021; Published: November 08, 2021

Abstract

Tuberculosis is a chronic infectious disease that affects millions of people. The system most affected is the respiratory system. Nodular hepatic TB without involvement of other organs is not common. Its clinical manifestations are not specific. The differential diagnosis includes primary and metastatic malignancies of the liver. We report a case of nodular hepatic TB revealed by molecular biology in a 69-year-old diabetic patient without any sign of TB impregnation and highlighting the contribution of molecular biology in the diagnosis and rapid management of this rare entity.

Keywords: Hepatic tuberculosis; Nodular; Molecular biology

Introduction

Tuberculosis (TB) is a growing problem worldwide; therefore, it is essential to recognize the more unusual presentations of this disease [1]. Intra-abdominal TB has a high mortality, but it is a difficult diagnosis to make, often requiring laparotomy. Nodular hepatic TB in particular is rare, with less than 100 cases reported in the literature, most of which are secondary and associated with miliary TB [1]. The symptomatology of nodular hepatic TB is nonspecific, and palpation of an abdominal mass may erroneously point to a malignant tumor pathology, furthermore as the symptomatology evolves in a context of altered general condition. This diagnosis, which is difficult and often unrecognized, must be evoked, especially if the epidemiological context lends itself to it in the presence of a concomitant pulmonary disease or a history of TB [2].

The diagnosis of nodular hepatic TB is difficult due to the variability of clinical presentations, non-specific biological data and the difficulty of access to certain sampling sites, resulting in paucibacillary specimens that reduce the sensitivity of conventional diagnostic tests. The advent of molecular tests seems to bring a considerable gain in the diagnosis of extra pulmonary TB, especially in pauci-bacillary specimens [2]. We report a case of nodular hepatic TB revealed by molecular biology in a 69-year-old diabetic patient without any sign of TB impregnation, emphasizing the contribution of molecular biology in the diagnosis and the rapid and efficient management of this rare pathology.

Case Presentation

O.H is a 67-year-old man with type 2 diabetes on oral antidiabetics with poor compliance. He had a history of thrombophlebitis of the right lower extremity 2 years ago. In addition, he had no history of TB or contact with other TB patient.

10 days before his hospitalization, the patient presented a pain in the right hypochondrium, associated with frontal headaches, without digestive, urinary or respiratory symptoms (no cough, no hemoptysis), all evolving in a context of fever at 39°c, night sweats, asthenia, and a weight loss (not quantified).

The clinical examination found a febrile patient at 38.5°c, normotensive, eupneic, with normo-colored conjunctiva.

Palpation revealed tenderness of the right hypochondrium without hepatomegaly or splenomegaly. The lymph nodes were free and the rest of the somatic examination was unremarkable.

Biochemical blood analysis showed A raised C-Reactive protein (CRP) at 364mg/l, a hyperleukocytosis at 15300/ml with a predominance of PNN (93%), a thrombocytopenia at 91000/ ml, a disturbance of the hepatic balance with GGT (Gamma glutamyl transferase) at 113 UI/l (VN : 25- 50 IU/l), PAL ( Alkaline phosphatases) at 105 IU/l ( VN: 32- 91 IU/l) a normal bilirubinemia, ALAT (Alanine amino transferase) at 56 IU/l (VN: 15- 35IU/l) and ASAT (Aspartateamino transferase) at 58 IU/l ( VN: 20- 45IU/l), The prothrombin time was at 67%. Procalcitonin was positive at 35ng/ ml and blood cultures were positive for Klebsiella pneumoniae. Viral serologies B, C and HIV were negative. Chest X-ray, abdominal ultrasound, trans-thoracic and trans-esophageal echocardiography were unremarkable. The patient was initially put on antibiotic therapy but without clinical and biological improvement after 8 days of treatment (persistence of fever and the inflammatory syndrome with a CRP at 185mg/l).

Subsequently, a thoracic-abdominal-pelvic CT scan showed scattered bilateral subpleural nodules, some of which were calcified, with mediastinal adenopathy, the largest of which was located at the 4L chain and measured 10 mm in minor axis. In the abdominal and pelvic region, the liver was steatotic, normal in size and regular in outline, with a round hypodense lesion of the hepatic dome with peripheral enhancement measuring 28 mm x 21 mm, and two welllimited hypodense lesions of segments IV and V measuring 10 mm and 12 mm in diameter respectively (Figure 1).

Citation: Benaissa E, Elbnaissi Y, Reggad A, Oucharqui S, Bssaibis F, Jidane S, et al. Nodular Hepatic Tuberculosis about a Case: An Underestimated Diagnosis. J Bacteriol Mycol. 2021; 8(6): 1189.