A 45-year-old female was diagnosed with HIV infection in December 2013. She was started on highly active antiretroviral therapy comprising tenofovir 300 mg once daily (OD), lamivudine 300 mg OD and nevirapine 200 mg twice daily 5 months back, which she was tolerating well. Her CD4 count was 417 cells mul-1. She presented to us in June 2014 with pain in the right upper quadrant of 3 months duration that was intermittent, colicky, moderate in intensity and radiating to the infrascapular area, suggesting a biliary origin and requiring i.v. analgesics on multiple occasions. She also had low-grade fever, anorexia and weight loss of the same duration. There was no jaundice or other systemic features. Clinical examination revealed a 3-cm firm hepatomegaly; there was no peripheral lymphadenopathy and the rest of the clinical examination was unremarkable. Blood investigations suggested mild anaemia (Hb 10.2 g dl-1), elevated erythrocyte sedimentation rate (47 mm in the firsthour) and deranged liver function tests [serum bilirubin: 0.6 mg dl-1; albumin 4.0 g dl-1; aspartate aminotransferase 49 U l-1; alanine aminotransferase 145 U l-1; alkaline phosphatase 460 U l-1 (normal 42-128 U l-1)]. Ultrasonography of the abdomen showed mild central intrahepatic biliary radical dilatation with a dilated common bile duct (CBD) and multiple periportal and peripancreatic lymph nodes, the largest measuring 10 mm in diameter. Dynamic contrast-enhanced MRI and MR cholangiopancreatography were performed, which revealed a dilated CBD with an abrupt cut-off of the distal CBD with few subcentimetre lymph nodes (Figure 1). Mantoux test was positive with an induration of 25 x 25 mm at 72 h. Ultrasound-guided FNAC from periportal lymph nodes was performed with a 22-gauge spinal needle and two passes were obtained with the same needle on two separate occasions 1 week apart. However, on cytological examination, the aspirate was bloody and no conclusive diagnosis could be offered by the cytopathologist.
15 days after the second FNAC, the patient developed a painful skin nodule at the site of insertion of the FNAC needle. The nodule measured 1 x 1 cm and was erythematous, well-defined, firm and mildly tender, as shown in Figure 2 (indicated by arrow). FNAC tract seeding by tuberculosis was suspected and excision biopsy of the nodule was performed.
Biopsy of the skin revealed many scattered, ill-formed epithelioid cell granulomas and Langerhans-type giant cells, and periappendageal and perivascular lymphohistiocytic infiltrate admixed with neutrophils and eosinophils. Ziehl-Neelsen stain for acid-fast bacilli was positive (Figure 3). The overall features were suggestive of tubercular granuloma.
The patient was started on weight-based standard antitubercular therapy with four drugs (isoniazid 200 mg OD, rifampicin 400 mg OD, pyrazinamide 1 g OD and ethambutol 800 mg OD). On follow-up visits, the patient showed good clinical response:fever and pain had subsided, appetite had improved and there was gain in weight. Liver function tests normalized and erythrocyte sedimentation rate decreased to <20 mm in the first hour. A CT scan of the abdomen revealed significant decrease in the size of the periportal and peripancreatic lymph nodes. There was no evidence of biliary dilatation. The patient was doing clinically well after 6 months of antitubercular therapy.