Mass-like hepatic tuberculomas

Case contributed by Dr Vincent Tatco

Presentation

Patient presented with epigastric pain with palpable abdominal mass.

Patient Data

Age: 30
Gender: Female
CT

The liver is not enlarged. There is a faintly enhancing lobulated hypodense mass lesion measuring 6.5 x 10.3 x 12.0 cm (AP x T x CC) at segments II/III of the liver, with more pronounced involvement of segment III and with an exophytic component having a small faintly calcified focus. Another faintly enhancing ill-marginated hypodense ovoid mass lesion, measuring 5.5 x 6.3 x 7.5 cm (AP x T x CC), is seen at hepatic segment IV. Small non-enhancing hypo densities, probably cysts, are demonstrated at segment VIII near the dome, segment II and junction of segment IV and VIII. The intrahepatic ducts are not dilated. The portal vein is patent.

There are enlarged lymph nodes in the left para-aortic and gastrohepatic areas measuring 1.9 x 1.2 cm and 1.3 x 0.8 cm, respectively. There is also apparent fullness in the region just on top of the gastroesophageal junction with approximate size of about 1.8 x 1.9 cm (AP x T) which raises the possibility of an enlarged lymph node. Another lower right paraesophageal ovoid structure with a tiny eccentric calcification suggestive of an enlarged mediastinal lymph node measuring 2.4 x 3.9 cm (AP x T) is demonstrated. Enlarged right anterior supradiaphragmatic lymph node is also observed.

The spleen is top normal in size with a subcentimeter non-enhancing hypodensity, probably a cyst, at its most supero-anterior aspect.

Incidentally, there are multiple subcentimeter non-calcified nodules in the right lower lobe of the lungs. There is a calcified nodule measuring 0.3 cm in the lingular segment. Minimal nodular pleural thickening is also appreciated in the right posterior pleural surface. There is also a 1.3 x 0.9 cm (AP x T) ovoid structure in the right lower lobe abutting the pericardium of the right atrium which is possibly a circumcardiac lymph node or subpleural nodule.

MRI

There are lobulated confluent masses and nodules in the left lobe of the liver at segments II, III and IV. Discrete dominant masses are noted at segment III measuring 7.6 x 5.5 cm and segment IV measuring 6.1 x 5.3 cm. Previous report of 6.5 x 10.3 x 12.0 cm is the confluent measurement of the lesions seen on CT scan, it is essentially the same given the difference in imaging modalities. Lesions are better seen due to the contrast for MRI. Signal intensities of the lesions are low on T1-weighted images and hyperintense on T2-weighted images. Post-contrast images show arterial enhancement and no relevant uptake on the liver specific phase.  A small focus of hypointense signal is seen in the segment III lesion which corresponds to the faint calcified focus in the prior CT scan.

There are enlarged lymph nodes in the left paraaortic, gastrohepatic, porta hepatis, paraesophageal and right cardiophrenic regions. The largest measures 2.4 x 3.9 cm.

The spleen is prominent in size without discrete mass lesion. The gallbladder, pancreas, both adrenal glands and kidneys are normal. The osseous structures show no abnormal marrow signal.

There are nodular structures along the pleura in the right.

Biopsy of one of the hepatic lesions showed necrotizing granulomatous inflammation consistent with tuberculosis (TB).

TB blood test (interferon gamma release assay) was positive. 

Patient underwent anti-TB treatment.

CT

Follow-up CT scan after completion of anti-TB treatment, shows resolution of the hepatic masses and nodules with residual non-enhancing hypodensities at segment II, III and IVA measuring 2.9 x 2.8 cm and 2.0 x 1.2 cm suggestive of scars.  Punctate calcifications are present at segment III. No abnormal enhancement appreciated in all phases of the contrast-enhanced study.

No demonstrable enlarged lymph node or ascites at the time of examination.  

Case Discussion

This is a case of hepatic tuberculosis (TB) presenting as tumorlike masses. Hepatic TB is uncommon and accounts for less than 1% of all tuberculous infections. The disease may present at any age but is most commonly seen in young adults. The macronodular form of hepatic TB may present either as multiple 1 - 3 cm lesions or as a large tumorlike mass. Macronodular TB lesions have been referred to by a variety of names, including tuberculoma, pseudotumoral TB and tuberculous abscess. The imaging appearances of macronodular lesions are nonspecific and may appear identical to pyogenic abscess, metastases, and primary liver tumors such as hepatocellular carcinoma and cholangiocarcinoma. Cross-sectional imaging alone may be insufficient in reaching a conclusive diagnosis, and image-guided biopsy is needed in most cases to obtain a definitive histological diagnosis.

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Case information

rID: 43141
Case created: 25th Feb 2016
Last edited: 2nd Mar 2016
Inclusion in quiz mode: Included

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