A 50-year-old female patient referred to our hospital with a history of mild abdominal pain, located in the epigastrium and in the right upper quadrant, lasting for more than a month. In addition, she complained about weight loss (4 kg during last month), loss of appetite, and low-grade fever. At the time of administration, the patient weighted at 65 kg with a height of 162 cm (BMI: 24.77 kg/m2). There were no night sweats, cough, vomiting, nor dysuria. She suffered from hypertension, diabetes mellitus type 2, dyslipidemia, and seizures for which she was treated with the appropriate medication.
During the physical examination, the patient was presented with a blood pressure of 147/93 mmHg, pulse rate of 78/min, temperature of 37.4 C, and 17 breaths/min. She appeared pale. There was moderate tenderness of the right upper quadrant with hepatomegaly of three finger-breadths without splenomegaly, jaundice, nor ascites. The physical examination of the thorax did not reveal any abnormality, and no lymphadenopathy was detected.
Complete blood count revealed mild normocyte anemia (hemoglobin = 11.0 g/dl) and an erythrocyte sedimentation rate of 45 mm/h. Biochemical tests showed elevated alanine transaminase (355iU/L), aspartate aminotransferase (339iU/L), and alkaline phosphatase levels (302 iU/L) with normal renal function and electrolytes profile.
The ultrasonography (US) of the abdomen demonstrated a mass in the right lobe of the liver characterized by mixed echogenity. An abdominal computed tomography (CT) followed, which demonstrated a hypodense mass in the right lobe of the liver next to a nonenhanced mass, with normal borders and a size of 1.8 cm, in the right adrenal gland consistent with a benign tumor. Neither chest X-ray nor CT revealed any other abnormal findings. The magnetic resonance imaging (MRI) of the abdomen showed hypointense and hyperintense multiple nodular lesions in T1-weighed imaging and T2 weighed-imaging, respectively, with abnormal borders with a greatest size of 2 cm (Figure 1). In addition, these lesions demonstrated enhancement after IV contrast administration. The initial differential diagnosis of these radiological findings included primary hepatocellular carcinoma or metastasic liver lesions. As a result, a core biopsy of liver mass with the assistance of ultrasound was conducted. It showed infiltration of predominant eosinoplils, lymphocytes, plasmatocytes, and some giant cells with epitheloid necrotic granulomas (Figure 2). No fungus or acid-fast bacilli were found in the specimen, and a parasite infection was suspected due to eosinophils presence, but it was unable to exclude malignancy or liver pseudotumor. A hepatectomy, including the VI segment of the right lobe of the liver, was performed, and the histopathological examination revealed multiple granulomas with central caseating necrosis. These findings are consistent with tuberculosis even though there were no acid-fast bacilli in Ziehl-Neelsen staining (Figure 3). A QuantiFERON-Tb test was conducted and turned out positive. Lastly, the patient was tested for human immunodeficiency virus (HIV) status, which was negative.
The antituberculous scheme, administrated to the patient, included isoniazid, rifampicin, pyrazinamide, and ethambutol for two months and isoniazid rifampicin for four months more. There were no serious adverse events observed, and all symptoms and laboratory findings were normal after completion of the treatment. Seven months postoperatively, the patient remains fit and healthy.