Enlarged cervical lymph nodes and elevated liver chemistry tests: a therapeutic dilemma.
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.
Dietrich
Christoph G
CG
Department of Medicine III, Aachen University, 52074 Aachen, Germany.
Gartung
Carsten
C
Lorenzen
Johann
J
Geier
Andreas
A
Wasmuth
Hermann E
HE
Matern
Siegfried
S
Lammert
Frank
F
D000328:Adult; D000995:Antitubercular Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001706:Biopsy; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology; D004359:Drug Therapy, Combination; D004977:Ethambutol / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D007538:Isoniazid / Q000008:administration & dosage* / Q000009:adverse effects; D008099:Liver / Q000187:drug effects* / Q000382:microbiology / Q000473:pathology; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D011718:Pyrazinamide / Q000008:administration & dosage / Q000009:adverse effects; D012293:Rifampin / Q000008:administration & dosage / Q000009:adverse effects; D014386:Tuberculosis, Hepatic / Q000188:drug therapy* / Q000473:pathology; D014391:Tuberculosis, Miliary / Q000188:drug therapy* / Q000473:pathology
D000995:Antitubercular Agents; D011718:Pyrazinamide; D004977:Ethambutol; D007538:Isoniazid; D012293:Rifampin