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

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