Isolated hepatic tuberculoma: A case report and review of the literature

Table 1 Laboratory findings of the liver function in the clinical course

Test	Unit	2022			2023		2024
		January 16	May 10	September 6	March 10	November 16	December 25
T-Bil	mg/dL	1.59	0.58	0.80	0.42	0.55	0.51
AST	IU/L	170	13	14	13	15	36
ALT	IU/L	295	14	12	10	15	70
γ-GTP	IU/L	202	32	30	26	22	22
LDH	IU/L	239	160	168	158	188	194
ALP	IU/L	186	71	70	64	61	69
Cr	mg/dL	NP	0.76	0.80	0.79	0.78	0.89
CRP	mg/dL	2.52	NP	NP	NP	NP	NP
Plt	104/μL	NP	NP	19.3	19.8	20.3	22.3

T-Bil: Total bilirubin; AST: Aspartate aminotransferase; ALT: Alanine transaminase; γ-GTP: γ-glutamyl transpeptidase; LDH: Lactate dehydrogenase; ALP: Alkaline phosphatase; Cr: Creatine; CRP: C-reactive protein; Plt: Platelet; NP: Not performed.

Table 2 Timeline of imaging findings and lesion characteristics

Date	Modality	Lesion size	Imaging features
January 17, 2022	MRCP	Approximately 28 mm	Abnormal signal focus in the caudate lobe, associated with bile duct stenosis and proximal biliary dilation. Enlarged hilar lymph nodes
January 18, 2022	Abdominal CT	Approximately 20 mm	Subtle hypodense lesion in the caudate lobe with mild enhancement. Enlarged lymph nodes in the hepatic hilum and retroperitoneum with ring enhancement
January 20, 2022	Abdominal MRI	Approximately 26 mm	Irregular, mixed-signal foci in the caudate lobe with mildly prolonged T1/T2 signals, diffusion restriction, and ring enhancement. Markedly enlarged and enhanced lymph nodes in the hepatic hilum
January 24, 2022	Abdominal ultrasound	50.5 mm × 25.5 mm	Hypoechoic mass in liver segment I (S1), with internal hyperechoic changes, seen encircling the portal vein

MRI: Magnetic resonance imaging; CT: Computed tomography; MRCP: Magnetic resonance cholangiopancreatography.

Table 3 Diagnosis and treatment process of this case

Date	Action	Outcome
January 16, 2022	Hospital admission	Admitted with a 5-day history of epigastric pain
January 16-18, 2022	Initial laboratory and imaging investigations	Elevated liver enzymes (ALT 295 U/L AST170U/L). CT/MRCP identified a 20-28 mm hypodense lesion in the caudate lobe with enlarged, rim-enhancing lymph nodes
January 20, 2022	Abdominal MRI with contrast	Confirmed irregular mixed-signal foci in the caudate lobe
January 24, 2022	EUS-FNA	Tissue samples obtained from the liver lesion and adjacent lymph nodes
January 24, 2022	Cytological examination report	Specimen showed necrotic background with lymphocytes, multinucleated giant cells, and epithelioid cells
January 26, 2022	Gene-Xpert (MTB/RIF)	Mycobacterium tuberculosis DNA detected (low levels). No rifampicin resistance detected
January 27, 2022	Antitubercular therapy initiated	Standard HRZE regimen initiated (isoniazid, rifampin, ethambutol, pyrazinamide)
January 28, 2022	Pathological and genetic	Histopathology confirmed granulomatous inflammation with necrosis. TB RT-PCR was positive
January 30, 2022	Hospital discharge	Discharged in stable condition on anti-TB medications
May 10, 2022	Outpatient follow-up visits	The treatment compliance was good, and no significant adverse reactions were reported. Ultrasound showed a 2.5 cm × 1.7 cm slightly hypoechoic area in the caudate lobe of the liver; Another 1.5 cm × 1.2 cm slightly high echo area can be seen
Monthly	Outpatient follow-up visits	Good treatment compliance with no significant adverse effects reported
November 17, 2023	Final imaging follow-up	Ultrasound confirmed complete resolution of the liver lesion, indicating clinical cure
November, 2023	Completion of anti-TB therapy	Total treatment duration: 22 months

TB: Hepatic tuberculosis; RT-PCR: Reverse transcription-polymerase chain reaction; HRZE: Isoniazid, rifampicin, pyrazinamide, and ethambutol; CT: Computed tomography; MRCP: Magnetic resonance cholangiopancreatography; MRI: Magnetic resonance imaging; EUS-FNA: Endoscopic ultrasound-guided fine-needle aspiration biopsy; ALT: Alanine transaminase.

Table 4 Summary of case reports of liver tuberculosis

No.	Ref.	Age	Immune status	Lesion location	Diagnostic method	IGRA result	Treatment duration	Outcome
1	Chen et al[21], 2003	56	Hepatitis C-related liver cirrhosis and end-stage renal disease	Liver segments IV, V	Ultrasound-guided biopsy	Not mentioned	Isoniazid, rifampicin, pyrazinamide, ethambutol for 6 months	Good recovery, asymptomatic at 1-year follow-up
2	Culafic et al[22], 2005	57	Immunocompetent	Liver segments III, IV and peritoneum	Laparoscopic biopsy	Not mentioned	Isoniazid, rifampicin and pyrazinamide for 12 months	Good recovery
3	Köksal et al[23], 2006	48	Diabetes mellitus	Posterior segment of right hepatic lobe	Ultrasound-guided percutaneous biopsy	Not mentioned	Isoniazid, rifampicin for 9 months; morphine floxacin, ethambutol for 3 months	Cure, abscess reduced in size
4	Kharrasse et al[5], 2014	44	Benign gastroesophageal reflux disease	Hepatic SVIII segment	Liver biopsy	Not mentioned	Isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, then isoniazid, rifampicin, and ethambutol for 4 months	Good recovery
5	Zhang et al[24], 2014	30	Hepatitis B history, pulmonary tuberculosis	Liver (multiple nodules)	CT-guided fine needle aspiration biopsy	Not mentioned	Rifampicin, isoniazid, pyrazinamide, ethambutol, plus prednisone and dioxacin for 1 year	Recovery, weight gain, normal CT at 6 months
6	Liao et al[25], 2015	40	Immunocompetent	Lung and liver	CT-guided percutaneous biopsy of the lung and liver	Not mentioned	INH, RFP, PZA, EMB (HRZE)	Symptoms relieved
7	Dawani et al[26], 2018	32	Immunocompetent	Liver and spleen	Ultrasound-guided fine needle aspiration biopsy	Quantiferon-TB test negative	Anti-tuberculous therapy for 6 months	Recovery, weight gain, ultrasound normal at 15-month follow-up
8	Ai et al[27], 2018	45	Immunocompetent	Liver (multiple masses)	Next-generation sequencing of liver tissue and ultrasound-guided biopsy	T-SPOT, TB positive	Rifampicin, isoniazid, ethambutol, pyrazinamide, levofloxacin	Symptom resolution, asymptomatic at 8-week follow-up
9	Liang et al[28], 2018	58	Immunocompetent	Pancreas and liver	CT-guided fine needle aspiration biopsy of hepatic lesion	Not mentioned	Rifampicin, isoniazid, pyrazinamide, ethambutol for 2 months, then rifampicin and isoniazid for 4 months	Symptom resolution, asymptomatic at 2-year follow-up
10	Haque et al[29], 2019	58	Immunocompetent	Liver and gallbladder region	Peroperative frozen section biopsy	Not mentioned	Anti-tuberculous treatment for 1 year	Improvement, symptoms disappeared, weight gain
11	Pang et al[30], 2019	15	Immunocompetent	Hilar region of the liver	Postoperative pathological examination	The results of TBAB and T-SPOT were negative	Systemic anti tuberculosis treatment, a total of 6 months	Symptoms disappeared completely
12	Alsaif et al[31], 2021	47	Immunocompetent	Liver (HCC and tuberculosis co-existing)	CT-guided biopsy	Not mentioned	Rifampicin, isoniazid, ethambutol, levofloxacin; duration not specified	Clinical improvement, fever resolved, tumor not resected
13	Hao et al[32], 2023	38	Hepatitis B history, hepatobiliary adenocarcinoma	Liver	Postoperative pathology	Not mentioned	Standard antituberculous treatment for 1 year	Recovery well
14	Hao et al[32], 2023	51	Immunocompetent	Liver	Laparoscopic biopsy	Not mentioned	Rifampicin, isoniazid, pyrazinamide, ethambutol for 2 months, then rifampicin and isoniazid for 4 months	Abdominal pain resolved, good outcome

IGRA: Interferon-gamma release assay; INH: Isoniazid; RFP: Rifampicin; PZA: Pyrazinamide; EMB: Ethambutol; HRZE: Isoniazid, rifampicin, pyrazinamide, ethambutol; CT: Computed tomography; T-SPOT: Enzyme-linked immunospot assay for T cells for Mycobacterium tuberculosis infection; TB: Tuberculosis.