A 44-year-old man with a history of benign gastroesophageal reflux disease (GERD), with irregular use of IPP, visited the emergency department with the chief complaint of intermittent fever for 3 months. Body weight loss (11 kg/month), abdominal fullness, poor appetite, and general malaise were also observed. He had no significant history of tuberculosis, and no relevant familial history. On direct questioning he admitted to have night sweats and abdominal pain. The patient said that he had received outpatient treatment followed by oral antibiotics. Unfortunately, his condition worsened with intermittent chills and body weight loss, so he was referred to our hospital. On admission, we found a mildly cachetic man. No jaundice was noted by examination of the palpebral or bulbar conjunctiva, but he was found to be pyrexial (38.7 C on admission). His heart rate was 91 beats/min, blood pressure was 135/89 mmHg, respiratory rate was 18 breaths/min, and oxygen saturation was 100% under normal conditions. Physical examination revealed mild right hypochondrial knocking pain with right hepatomegaly. Palpation did not reveal any abnormalities in the gallbladder or spleen, no abnormality was noted by chest percussion and there was no lymphadenopathy.
The results of laboratory studies showed the following: an elevated C reactive protein (CRP) level of 152 (normal less than 10 mg/L). a mildly elevated erythrocyte sedimentation rate (ESR), and hyponatremia at 121mEq/L (Normal serum sodium levels are between approximately 135 and 145 mEq/L); a normal potassium value at 4.16 mEq/L (normal range between 3.5 and 5.0 mEq/L); white blood cell count (WBC) of 8500/mL (normal range, 3500-9100/mL); hemoglobin, 10.9 g/dL (normal range, 13.5-18 g/dL), platelet count, 280,000/muL (normal range, 157,000-377,000/ muL); aspartate aminotransferase (AST), 18 IU/L (normal range, 11-39 IU/L); alanine aminotransferase (ALT), 25 IU/L (normal range, 4-38 IU/L); total bilirubin, 2.2 mg/dL (normal range, 0.2-1.0 mg/dL); elevated creatinine, 3.2 mg/dL (normal range, 0.6-1.5 mg/dL); blood urea nitrogen (BUN), 21 mg/dL (normal range, 9-23 mg/dL). Prothrombin time was within normal limits. Further evaluations, including tests for human immunodeficiency virus, carcinoembryonic antigen, cancer antigen 19-9, alpha-fetoprotein, prostate-specific antigen, serologic diagnosis of hydatid disease and amoebic hemagglutination were all negative. Several sets of blood and sputum cultures were negative for bacteria, fungus, and acid-fast bacilli. Abdominal ultrasound revealed marked hepatomegaly with a tumor with an unclear border in the VIII subsegment of the liver consisting partially of hypoechoic mass, with the hyperechoic area measuring 7 cm. No ascites or adenopathy was seen. Similarly, Abdominal computed tomography (CT) revealed a low-density lesion approximately 7 cm in diameter at the SVIII segment, showing various fat concentrations. Chest X-ray examination was normal (Figure 1, Figure 2). Therefore, we scheduled a liver biopsy in order to rule out malignancy and to have a definitive diagnosis. The direct appreciation of the exudates did not reveal bacteria and histological study suggested an inflammatory pseudotumor with Langerhans giant cells and without caseous necrosis. Anti-TB medications including isoniazid, rifampin, ethambutol, and pyrazinamide were administered accordingly. The fever subsided within 1 week, and the patient's appetite was restored gradually. The patient completed the 6-month course of medication (2 months with isoniazid, rifampin, ethambutol, and pyrazinamide, followed by 4 months with isoniazid, rifampin, and ethambutol) without severe adverse events. WBC count, CRP, and ESR all returned to normal levels. The patient's appetite and body weight were restored to previous levels. The follow-up abdominal CT scan revealed that the lesion at the S8 segment had decreased in size after 4 months of treatment and disappeared after one year of follow up. Follow-up was continued for six years, and the patient is still healthy.