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LETTER TO THE EDITOR
Gall Bladder TuberculosisMasquerading as Carcinoma:Dilemma Resolved by Aspiration Cytology
Dear Dr Bedrossian:
Gallbladder tuberculosis often mimics gallbladder carci-
noma in a patient presenting with gallbladder mass. Due
to lack of pathognomic features on radiology, gallbladder
tuberculosis is diagnosed only after histopathology of
resected specimen. This not only delays treatment but
also adds to financial and psychological burden related to
surgery. We present a 62-year-old male suffering from
episodic dull aching localized pain in the right hypochon-
drium for 6 months, loss of appetite and loss of weight
by 10 kg in the last 6 months, with no history of
fever, night sweats, jaundice, or lump in the abdomen.
He had history of adequately treated pulmonary tuber-
culosis 20 years back. There was no history of recent
tuberculosis in the family members or neighbors. On ex-
amination, patient was of thin built and poor nutrition,
and he weighed 45 kg with a height of 165 cm. No
signs of jaundice, clubbing, lymphadenopathy, or pedal
edema were noticed. His abdomen was soft, with no
evidence of any lumps, tenderness, rebound tenderness,
or free fluid. Rest of the systemic examination was nor-
mal. Blood tests revealed normal blood counts, blood
sugar, blood urea, and serum creatinine. Liver function
tests showed ALT-30 U/L, AST-37 U/L, ALK-211 U/L,
and total serum bilirubin-0.6 mg/dl. Serum protein and
albumin were 7.7 gm/dl and 4.1 gm/dl, respectively.
Chest x ray was normal.
Abdominal ultrasound revealed a thick irregular gall-
bladder wall with multiple calculi. Abdominal CT scan
showed a heterogeneous mass arising from the body and
fundus of the gallbladder that measured 7.7 3 5.1 cm.
Local infiltration of the mass into the segment four of
liver was noticed along with the perilesional necrotic
lymph nodes (Fig. 1).
With a preoperative diagnosis of gallbladder carcinoma
on the basis of radiological findings, ultrasound guided
fine-needle aspiration (FNA) was performed using all
aseptic measures. Cytological smears were cellular and
revealed numerous well-formed epithelioid cell granuloma
(Fig. 2a) composed of slipper shaped epithelioid histio-
cytes (Fig. 2b) admixed with lymphocytes, plasma cells
and few neutrophils along with Langhan’s and foreign
body type of giant cells (Fig. 2c), with necrosis in
Fig. 1. Axial CT abdomen showing gallbladder mass arising from bodyand fundus measuring 7.7 3 5.1 cm and adherent to liver segment four.
*Correspondence to: Ritu Verma, M.D., Department of Pathology,Sanjay Gandhi Postgraduate Institute of Medical Sciences, RaebareliRoad, Lucknow, 226014, India. E-mail: dr_rituverma@rediffmail.com
Received 23 June 2010; Accepted 21 October 2010DOI 10.1002/dc.21604Published online 30 December 2010 in Wiley Online Library
(wileyonlinelibrary.com).
' 2010 WILEY PERIODICALS, INC. Diagnostic Cytopathology, Vol 40, No 1 91
the background. Zeihl Neelson stain showed few positive
acid fast bacilli (Fig. 2d). No evidence of malignancy
was found. Patient was started on four drug antitubercular
treatment as per WHO category 1 protocol for treatment
of systemic tuberculosis.1 His abdominal pain reduced
significantly after 15 days of antitubercular treatment.
After 2 months of antitubercular treatment, patient
had complete subsidence of right hypochondrial pain
with improvement in appetite and weight gain by 4 kg.
Repeat CT abdomen after 5 months of antitubercular
treatment revealed complete subsidence of gallbladder
mass (Fig. 3).
About 40% of Indian population is estimated to be
affected with tuberculosis. Abdominal tuberculosis is
the third commonest cause of tuberculosis after
lymphnode and central nervous system tuberculosis
and comprise 17% of extrapulmonary tuberculosis. In-
testinal, omental, and retroperitoneal lymphnodes are
common sites of abdominal tuberculosis. The gallblad-
der tuberculosis is extremely rare.2 High alkaline bile
and bile acids inhibits the growth of tubercular bacilli
and make gall bladder an uncommon site for tubercu-
losis.2 However, due to nonspecific infection of the
gallbladder, the resistance of gallbladder to tubercular
bacilli is somehow lost. In addition, immune compro-
mised states make a person prone for gallbladder tu-
berculosis. Four distinct clinical varieties of gallblad-
Fig. 3. Axial CT abdomen after 5 months of antitubercular treatmentshowing normal gallbladder with complete subsidence of gallbladdermass.
Fig. 2. (a) Photomicrograph displaying well-defined granuloma with giant cells (H&E, 3100). (b) Higher magnification reveals numerous slippershaped epithelioid cells with areas of necrosis (H&E, 3200). (c) Multinucleated Giant cell (H&E, 3200). Acid Fast bacilli (Zeihl Neelson stain, oilimmersion) [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com].
VERMA ET AL.
92 Diagnostic Cytopathology, Vol 40, No 1
Diagnostic Cytopathology DOI 10.1002/dc
der tuberculosis are recognized.3 (1) As a component
of miliary tuberculosis in children and in adults,
(2) As a component of disseminated abdominal tuber-
culosis, (3) Isolated gallbladder tuberculosis without
overt tubercular foci elsewhere in the body, and (4)
Involvement of gallbladder in anergic states due to
uremia, cancer or AIDS. Majority of patients with
gallbladder tuberculosis belongs to group 3 variant
that also includes the present case.
Preoperative FNA of the gallbladder mass is usually
not performed routinely. Only two cases of gallbladder
tuberculosis were found where preoperative FNAC was
performed.4,5 In both the cases, preoperative FNA proved
nonconclusive and definite diagnosis of gallbladder tuber-
culosis was reached on histopathology of the resected
specimen. Nonspecific findings on FNA of gallbladder
mass could be due to targeting a nonrepresented area of
gallbladder, inadequate aspirate, less extensive disease,
and failure to use stains for acid fast bacilli. Radiological
investigations like ultrasound and CT abdomen also
shows nonspecific findings and contributes little to the
diagnosis of gallbladder tuberculosis. All the previously
reported cases of gallbladder tuberculosis were diagnosed
on the histopathology of the resected specimen.
In summary, gallbladder tuberculosis may mimic malig-
nancy in a patient presenting with a gallbladder mass.
Because of nonspecific findings on abdominal radiology,
surgery followed by histopathology seems to be the
only option to yield correct diagnosis. FNA from the
gallbladder mass however, should be done early in
the preoperative period in these patients. Positive cytology
for tuberculosis may prevent unnecessary surgery and
delay in initiating the definite conservative treatment.
Ritu Verma, M.D.*
Mukul Vij, M.D.
Lily Pal, M.D.
Department of Pathology
Sanjay Gandhi Postgraduate Institute of Medical Sciences
Raebareli Road
Lucknow, India
References1. World Health Organization. Global tuberculosis control 2008:
Surveillance, planning, financing. WHO/HTM/TB/2008.393. Geneva,Switzerland: WHO, 2008. Available at: http://www.int/tb/publications/global_report/2008/en/index.html. Accessed April 2009.
2. Yu R, Liu Y. Gallbladder tuberculosis: case report. Chin Med J(Engl) 2002;115:1259–1261.
3. Basu S, Ganguly S, Chandra PK, Basu S. Clinical profile and out-come of abdominal tuberculosis in Indian children. Singapore Med J2007;48:900–905.
4. Garg P, Godara R, Karwasra RK, Jain R, Yadav V. A palpablyenlarged gallbladder can be tubercular. Indian J Gastroenterol2001;20:120.
5. Kumar K, Ayub M, Kumar M, Keswani NK, Shukla HS. Tuberculo-sis of the gallbladder. HPB Surg 2000;11:401–404.
GALL BLADDER TUBERCULOSIS MASQUERADING AS CARCINOMA
Diagnostic Cytopathology, Vol 40, No 1 93
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