title: Enlarged cervical lymph nodes and elevated liver chemistry tests: a therapeutic dilemma.
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.
authors.affiliation: Department of Medicine III, Aachen University, 52074 Aachen, Germany.
authors.forename: Christoph G
authors.initials: CG
authors.lastname: Dietrich
authors.forename: Carsten
authors.initials: C
authors.lastname: Gartung
authors.forename: Johann
authors.initials: J
authors.lastname: Lorenzen
authors.forename: Andreas
authors.initials: A
authors.lastname: Geier
authors.forename: Hermann E
authors.initials: HE
authors.lastname: Wasmuth
authors.forename: Siegfried
authors.initials: S
authors.lastname: Matern
authors.forename: Frank
authors.initials: F
authors.lastname: Lammert
mesh_terms: 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
chemical_list: D000995:Antitubercular Agents; D011718:Pyrazinamide; D004977:Ethambutol; D007538:Isoniazid; D012293:Rifampin