A systematic review of hepatic tuberculosis with considerations in human immunodeficiency virus co-infection.
BACKGROUND
Mycobacterium tuberculosis (TB) infection of the liver, known as hepatic TB, is an extrapulmonary manifestation of TB. Hepatic TB has become more prevalent, likely as a result of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic. We sought to review case series to characterize the epidemiology, pathophysiology, clinical features, diagnosis, and treatment of hepatic TB and to comment on the impact of HIV co-infection on these characteristics.


METHODS
We conducted a systematic literature search in PubMed and ScienceDirect for articles pertaining to hepatic TB with human subjects from 1960 to July 2013.


RESULTS
We obtained data on 618 hepatic TB patients from 14 case series. The most common reported signs and symptoms were hepatomegaly (median: 80%, range: 10-100%), fever (median: 67%, range: 30-100), respiratory symptoms (median: 66%, range: 32-78%), abdominal pain (median: 59.5%, range: 40-83%), and weight loss (median: 57.5%, range: 20-100%). Common laboratory abnormalities were elevated alkaline phosphatase and gamma-glutamyl transferase. Ultrasound and computerized tomography (CT) were sensitive but non-specific. On liver biopsy, smear microscopy for acid-fast bacilli had a median sensitivity of 25% (range: 0-59%), histology of caseating granulomas had a median sensitivity of 68% (range: 14-100%), and polymerase chain reaction for TB had a median sensitivity of 86% (range: 30-100%). Standard anti-tuberculous chemotherapy for 6 to 12 months achieved positive outcomes for nearly all patients with drug-susceptible TB.


CONCLUSIONS
Clinicians in TB-endemic regions should maintain a high index of suspicion for hepatic TB in patients presenting with hepatomegaly, fever, respiratory symptoms, and elevated liver enzymes. The most sensitive imaging modality is a CT scan, while the most specific diagnostic modality is a liver biopsy with nucleic acid testing of liver tissue samples. Upon diagnosis, 4-drug anti-TB therapy should promptly be initiated. HIV co-infected patients may have more complex cases and should be closely monitored for complications.
University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA. andrew.hickey@som.umaryland.edu.
Andrew J
AJ
Hickey
Department of Infectious Diseases, Nelson Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa. gounder@ukzn.ac.za.|Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa. gounder@ukzn.ac.za.
Lilishia
L
Gounder
Department of Infectious Diseases, Nelson Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa. moosay@ukzn.ac.za.
Mahomed-Yunus S
MY
Moosa
Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, USA. pdrain@partners.org.|Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA. pdrain@partners.org.
Paul K
PK
Drain
D000163:Acquired Immunodeficiency Syndrome / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D060085:Coinfection; D014943:Global Health; D006801:Humans; D009169:Mycobacterium tuberculosis; D021141:Nucleic Acid Amplification Techniques; D015995:Prevalence; D014386:Tuberculosis, Hepatic / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*