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Enlarged cervical lymph nodes and elevated liver chemistry tests: a therapeutic dilemma
Christoph G Dietrich1, Carsten Gartung, Johann Lorenzen
1Department of Medicine III, Aachen University, 52074 Aachen, Germany.
Insights
Tuberculosis can affect the liver, presenting unique challenges in treatment. Gradual dosing of standard anti-tuberculosis drugs, isoniazid, rifampicin, ethambutol, and pyrazinamide, can successfully manage drug-induced liver injury in these patients.
Area of Science:
- Hepatology
- Infectious Diseases
- Microbiology
Background:
- Tuberculosis (TB) can manifest with diverse liver involvement, posing diagnostic and therapeutic challenges.
- Granulomatous inflammation is a common histological finding in hepatic TB, but patterns can vary.
Observation:
- A 36-year-old male patient from India presented with cervical lymphadenopathy and elevated liver enzymes.
- Lymph node biopsy revealed necrotizing granulomas with Mycobacterium tuberculosis DNA.
- Liver biopsy showed granulomatous hepatitis without central necrosis, with positive PCR for mycobacteria.
Findings:
- Standard quadruple anti-TB therapy (isoniazid, rifampicin, ethambutol, pyrazinamide) initially caused a 10-fold increase in liver enzymes.
- Treatment interruption followed by gradual, step-wise re-administration of the same drugs was well-tolerated after liver enzymes normalized.
Implications:
- This case highlights the varied presentations of hepatic tuberculosis.
- Gradual dose escalation of standard anti-tuberculosis drugs is a viable strategy for managing drug-induced liver injury in TB patients.
- Careful monitoring and individualized treatment approaches are crucial for managing complex TB cases involving the liver.
Abstract:
We describe the case of a 36-years-old male patient, originating from India, who presented with enlarged cervical lymph nodes and elevated liver chemistry tests. Histologically necrosing granulomas were observed in the lymph nodes, and PCR revealed DNA from mycobacterium tuberculosis. However, in the liver biopsy granulomatous hepatitis without central necrosis was seen. With a positive PCR for mycobacteria from liver tissue and no evidence for other hepatic diseases we started drug treatment with standard quadruple regimen consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide. Five days after onset of therapy, liver chemistry tests rose 10-fold, forcing us to interrupt treatment. Gradual step-wise re-exposition with the same medication after return of liver chemistry tests to baseline was well tolerated without any further side effects. Liver involvement of tuberculosis can have many facets and may be treated by gradual dosing of standard drugs.
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