Tuberculosis is one of the well-described infectiousdiseases, which has a worldwide occurrence and is asso-ciated with various clinical manifestations (1). Hepatictuberculosis is one of the uncommon forms of extrapul-monary tuberculosis (1-4). In tuberculosis, involve-ment of liver is usually seen in association with pul-monary or miliary tuberculosis (1, 2, 5). Occurrence ofisolated hepatic tuberculosis without extrahepatic mani-festations is very rare (1-5). In both, isolated hepaticand systemic tuberculosis, hepatic involvement tends tobe multiple micro- or macronodular, whereas the singlenodule or mass form is rare (1-3, 6). Hence, hepatic tu-berculosis can mimic primary or metastatic liver malig-nancies (1). In the present study, we have reported someunusual findings on isolated hepatic tuberculosis, whichwas revealed to be infiltrative type of hepatic tuberculo-sis from CT scans and ultrasonograms.

Case Report

A 49-year-old female patient was admitted to our hos-pital with abdominal pain and fever from past 20 days.During the past four years, the patient had undergonerepeated intrahepatic biliary stone removals by chole-dochoscopy. Physical examination revealed neither he-patomegaly nor splenomegaly. Laboratory tests showedan elevated level of C-reactive protein (CRP), howeverher other tests were normal, including alkaline phos-phatase, erythrocyte sedimentation rate (ESR), α-feto-protein, and CA 19-9. Plain chest radiography was unre-markable. Abdominal CT revealed a very hypoattenuat-ing lesion in the right lobe of the liver (Fig. 1A). Therewas less enhancement of lesion when compared withrest of the liver parenchyma. There was neither lym-phadenopathy nor calcification in the abdomen.Abdominal ultrasonography revealed a very ill-defined,heterogenous, subtle low echogenicity in the right lobeof the liver. CT and ultrasonographic findings revealedthe presence of cholangiohepatitis associated with intra-hepatic biliary stones. The patient’s symptoms were re-lieved after administration of antibiotics, and after dis-charging she had no specific symptoms. Two months

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Hepatic Tuberculosis: Unusual CT and Sonographic Findings1

Jihyeon Cha, M.D., Jae Ho Byun, M.D., Seong Eon Yoon, M.D., Ye Ri Lee, M.D., Hyung Jin Won, M.D., Ah Young Kim, M.D., Yong Moon Sin, M.D., Pyo Nyun Kim, M.D.,

Hyun Kwon Ha, M.D., Moon-Gyu Lee, M.D.

A case of infiltrative type of hepatic tuberculosis is presented. Ultrasonography re-vealed a very ill-margined, heterogenously low echoic lesion in the right hepatic lobe.CT scans demonstrated a very ill-defined, geographic, hypodense lesion with minimalcontrast enhancement mimicking cholangiohepatitis or infiltrative tumor in the righthepatic lobe.

Index words : TuberculosisLiverComputed tomography (CT)Ultrasound (US)

1Department of Radiology, Asan Medical Center, University of UlsanCollege of MedicineReceived June 15, 2005 ; Accepted July 21, 2005Address reprint requests to : Jae Ho Byun, M.D., Department ofRadiology, Asan Medical Center, University of Ulsan College ofMedicine, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, Korea.Tel. 82-2-3010-4400 Fax. 82-2-476-4719 E-mail: jhbyun@amc.seoul.kr

later, follow-up CT revealed the expansion of a very ill-defined, geographic, hypodense lesion with subtle con-trast enhancement in the right lobe of the liver and anew, ill-defined, low-attenuating lesion in the left lobe ofthe liver (Figs. 1B and C). There was neither lym-phadenopathy nor calcification and no abnormal find-ings were observed on the CT scans. The patient wasreadmitted and underwent sonographically guided per-cutaneous liver biopsy of a very ill-margined, heteroge-

neously low echoic lesion in the right lobe of the liver(Fig. 1D). Histologic examination showed chronic granu-lomatous inflammation with caseous necrosis, whichwas consistent with tuberculosis (Fig. 1E). Ziehl-Neelsenstain of the specimen for Mycobacterium tuberculosiswas negative. Culture for Mycobacterium tuberculosisby employing the specimen was not performed. Anti-tu-berculous treatment with isoniazid, rifampin, ethambu-tol, and pyrazinamide was started, and the patient was

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C D

Fig. 1. A 49-year-old woman with he-patic tuberculosis.A. Enhanced CT scan shows a very ill-defined, hypodense lesion (arrows) inthe right lobe of the liver. There ispneumobilia in the left intrahepaticbile duct of the liver due to previous re-moval of biliary stone by chole-dochoscopy.B, C. Follow-up enhanced CT scans ob-tained two months after the initial CT,reveal the expansion of a very ill-de-fined, geographic, hypodense lesion (ar-rows) with minimal contrast enhance-ment in the right lobe of the liver and anew ill-defined, low-attenuating lesion(arrows) in the left lobe of the liver.D. Ultrasonogram shows a very ill-mar-gined, heterogenously low echoic lesion(arrows) in the right lobe of the liver.E. Photomicrograph of the lesion showschronic granulomatous inflammation(arrows) with caseous necrosis (aster-isk). (H & E stain, ×100)F. Thirteen weeks after initiation of an-ti-tuberculous treatment, a follow-upenhanced CT scan shows reduction ofhypoattenuating lesion (arrows) in theright lobe of the liver.

A B

E F

discharged from the hospital six days after initiation ofthe anti-tuberculous medication. Thirteen weeks afterinitiation of the anti-tuberculous treatment, follow-upabdominal CT revealed reduction of the hypoattenuat-ing lesions in both the lobes of liver (Fig. 1F). Wethought that the hypoattenuating lesion in the left lobeof the liver was also hepatic tuberculosis.

Discussion

Tuberculosis can affect virtually any organ system inthe body and can be devastating if left untreated. In re-cent years, the prevalence of tuberculosis in both im-munocompetent and immunocompromised individualshas increased, and this disease has become a subject ofuniversal concern. Isolated hepatic tuberculosis withoutextrahepatic involvement and the macronodular orpseudotumor forms are rare (1-3). Kok and Yapp (1) re-ported that only 5 (0.3%) of 1678 new cases of tubercu-losis represented isolated hepatic tuberculosis withoutextrahepatic involvement of tuberculosis. Hepatic tuber-culosis can be classified as follows (3): a) primary acutepulmonary tuberculosis with liver involvement; b) mil-iary tuberculosis; c) primary tuberculosis; d) tuberculo-ma (abscess); e) chronic pulmonary tuberculosis withliver involvement; and f) tuberculous cholangitis.

Hepatic tuberculosis can be diagnosed on CT scans asmicronodular (miliary) or macronodular (7). The micron-odular type manifests on CT scans as multiple, tiny, low-attenuation foci, each a few millimeters in diameter andit spreads throughout the liver. The macronodular type israre and manifests as diffuse liver enlargement withmultiple, hypodense lesions measuring from 1- to 3-cmin diameter or as a single tumor-like mass (1, 3, 6, 7).Contrast enhancement occurs in peripheral granuloma-tous tissue, and the central low density of caseationnecrosis shows less enhancement or homogenous mini-mal enhancement (5). As the time progresses, calcifica-tion of the lesion occurs and occasionally may becomeextensive (1). The ultrasonograms reveals the presence ofthe miliary form is that of a homogenous enlarged liveror a bright echo pattern, which is indistinguishable fromthat observed in liver cirrhosis or other cases of in-creased hepatic echogenicity (1, 8). The macronodularform is seen as multiple round hypoechoic nodules (1, 8).

In our case, CT revealed a very ill-defined, geographic,low-attenuation lesion with minimal contrast enhance-ment. There were some penetrating vessels through thehypoattenuating lesion. These CT findings were neither

micronodular nor macronodular. Ultrasonography alsorevealed a very heterogeneously hypoechoic lesion withill margin. The cause of cholangitis was unclear becauseeither tuberculosis or biliary stone could be the cause ofcholangitis.

When hepatic tuberculosis is present in the macron-odular form, it is often confused with metastasis, lym-phoma, sarcoidosis, and liver abscess (1, 2, 6, 8). In ourcase, because of the patient’s underlying biliary stonedisease, her hepatic lesion was initially mistaken fornonspecific cholangiohepatitis associated with biliarystones. It could also have been considered to be anotherinfiltrative disease such as lymphoma, amyloidosis orfatty deposition.

Because the radiologic and clinical findings of hepatictuberculosis have a low specificity, microbiological orhistopathologic examination of such specimens is need-ed in order to make a diagnosis. Histologically, a tuber-culous lesion is composed of central caseating necrosiswith surrounding epitheloid and giant cells and border-ing lymphohistiocytic cells (3, 8). The more unequivocalconfirmation is the discovery of tuberculous bacilli afterthe use of special stains and/or on subsequent cultures.Because the frequency of positive acid-fast smears islow, ranging from 0to 45%, the caseating necrosis canbe considered to be very suggestive and sufficient forthe diagnosis (8). The proper clinical setting and follow-up of liver recovery, under specific anti-tuberculosismedication, leads to final diagnosis (8).

This rare case shows the infiltrative type of hepatic tu-berculosis without extrahepatic involvement of tubercu-losis. In patients who are presented with protracted ill-ness and have an unusual lesion in the liver on cross-sectional images, biopsy must be performed for correctdiagnosis and suitable treatment must be given.

Acknowledgments

The authors thank Bonnie Hami, MA, Department ofRadiology, University Hospitals Health System,Cleveland, Ohio, for her editorial assistance in prepar-ing the manuscript.

References

1. Kok KYY, Yapp SKS. Isolated hepatic tuberculosis: report of fivecases and review of the literature. J Hepatobiliary Pancreat Surg1999;6:195-198

2. Kawamori Y, Matsui O, Kitagawa K, Kadoya M, Takashima T,Yamahana T. Macronodular tuberculoma of the liver: CT and MRfindings. AJR Am J Roentgenol 1992;158:311-313

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3. Levine C. Primary macronodular hepatic tuberculosis: US and CTappearances. Gastrointest Radiol 1990;15:307-309

4. Achem SR, Kolts BE, Grisnik J, MacMath T, Monteiro CB,Goldstein J. Pseudotumoral hepatic tuberculosis. J ClinGastroenterol 1992;14:72-77

5. Hayashi M, Yamawaki I, Okajima K, Tomimatsu M, Ohkawa S.Tuberculous liver abscess not associated with lung involvement.Intern Med 2004;43:521-523

6. Tritou I, Prassopoulos P, Daskalogiannaki M, Charoulakis N,

Papakonstantinou O, Gourtsoyiannis N. Miliary hepatic tubercu-losis not associated with splenic or lung involvement. ActaRadiologica 2000;41:479-481

7. Harisinghani MG, McLoud TC, Shepard JO, Ko JP, Shroff MM,Mueller PR. Tuberculosis from head to toe. RadioGraphics 2000;20:449-470

8. Blangy S, Cornud F, Sibert A, Vissuzaine C, Saraux JL, BenacerrafR. Hepatitis tuberculosis presenting as tumoral disease on ultra-sonography. Gastrointest Radiol 1988;13:52-54

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대한영상의학회지 2005;53:269-272

비특이적 간 결핵1

1울산대학교의과대학서울아산병원진단방사선과

차지현·변재호·윤성언·이예리·원형진·감아영·신용문·김표년·하현권·이문규

본 증례는 복부 초음파상 간 우엽에 경계가 불분명하고 불균질한 에코로 보이고 컴퓨터 전산화 촬영상 경계가 불분

명한 저음영의 조영증강이 미미한 소견을 보여 간 종괴로 오인했던 침윤적 간 결핵에 대한 예를 보고하고자 한다.