A 58-year-old man presented to the outpatient department of our hospital with recurrent fever (38-41.2 C) and weight loss (up to 16 kg) for over 2 months and was admitted for pyrexia of unknown origin (PUO). At the time of admission, the physical examination revealed a conscious man with the following characteristics: temperature 39.6 C, pulse rate 102 beats/min, blood pressure 100/75 mm Hg and respiratory rate 22 breaths/min. There was no jaundice or lymphadenopathy. Abdominal examination revealed no tenderness or ascites and no hepatosplenomegaly or any other palpable mass in his abdomen. Laboratory analyses revealed the following data: haemoglobin 11.0 g/dl, white blood cells 7,600/mm3 (70% neutrophils), blood platelets 207,000/mm3, blood urea 3.7 mmol/l and creatinine 56 mumol/l. Liver enzymes showed a total bilirubin level of 17 mg/l with a direct component of 10 mg/l. Alanine aminotransferase and aspartate aminotransferase levels were 30 and 36 U/l, respectively (the normal range for alanine aminotransferase is 5-40 U/l and that for aspartate aminotransferase is 8-40 U/l), and alkaline phosphatase levels were 702 and 561 U/l (the normal range for gamma-glutamyl transpeptidase is 11-50 U/l and that for alkaline phosphatase is 40-150 U/l). The C-reactive protein level was 56.8 mg/l (normal range 0.0-8.0 mg/l) and the erythrocyte sedimentation rate was 29 mm/h (normal range 0-15 mm/h for males). The levels of tumour markers, such as alpha-fetoprotein, carcinoembryonic antigen and carbohydrate antigen 19-9, were within the normal limits. The patient was non-reactive in HIV serology. A chest CT scan showed no lesion suggestive of TB but revealed mild bilateral hydrothorax and hydropericardium. US of the abdomen revealed a hepatic portal lymph node of 1.7 by 1.2 cm and gallbladder wall oedema. All other abdominal viscera appeared normal with no free fluid. An echocardiogram revealed moderate hydropericardium about 15 mm before the myocardium of the anterior free wall of the right ventricle. A contrast-enhanced CT scan of the abdomen revealed calcifications in the posterior segment of the right liver and lymph node enlargement in the hepatic portal, intraperitoneal and retroperitoneal regions (fig. 1a). Lymphoma, lymphatic TB and autoimmune tissue disease were initially suspected but the hydrothorax and hydropericardium were too small to obtain a sample, and the location of the intraperitoneal and retroperitoneal lymph nodes made them difficult to biopsy. Hence, the patient was referred for a whole-body PET/CT scan to find the lesion site for biopsy. The patient was injected with 350 MBq 18F-fluorodeoxyglucose (FDG) and after 120 min he underwent a head-to-toe scan in a dedicated PET/CT scanner (Biograph, Germany) and a standard uptake value was calculated. Abnormal diffuse hypermetabolic activity in the liver was observed, especially in the junction of the left and right liver, with maximum FDG standard uptake values of 8.81 and 12.47 at the delayed scan (180 min after the injection) (fig. 1), and a nodular hypermetabolic lesion was found in segments V and VI. The standard uptake values of lymph nodes in the mesentery and retroperitoneal space were 7.17 and 9.11, respectively, at the delayed scan. Primary liver lymphoma and hepatocarcinoma were suspected. In order to establish a diagnosis, an ultrasound-guided percutaneous liver biopsy was performed in segments V and VI, and 2 strips of liver tissue were extracted from the liver.
Histological examination of the biopsy showed a TB follicle with central caseous necrosis surrounded by lymphocytes, multinucleate giant cells and epithelioid macrophages, revealing several acid-fast bacteria (fig. 2). To further confirm the diagnosis, a T-SPOT TB test was performed and it was highly positive for ESAT-6 (>20) and CFP-10 (>20). The diagnosis of hepatic TB was confirmed.
Four drugs for anti-tubercular therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) with methylprednisolone 16 mg/day were started. At the 4-week follow-up the patient was asymptomatic and his body temperature had returned to normal. At the 3-month follow-up the patient had no hydrothorax or hydropericardium on chest CT and no enlargement of lymph nodes on abdominal US.