Clinical and biochemical profile of tuberculosis in patients with liver cirrhosis.
BACKGROUND
There is paucity of data on tuberculosis and antituberculous therapy (ATT) induced hepatotoxicity in patients with chronic liver disease.


OBJECTIVE
To study demographic, clinical characteristics of tuberculosis, pattern of drug induced liver injury and treatment responses to ATT in patients with liver cirrhosis.


METHODS
All cases of liver cirrhosis diagnosed with tuberculosis (TB) between January 2010 and June 2013 were enrolled. Drug induced liver injury (DILI) was defined as follows (1) an aspartate aminotransferase (AST)/alanine aminotransferase (ALT) value exceeding 3 times the normal upper limit if the baseline level was normal (<40 IU/L), or an AST/ALT exceeding 2 times the baseline level if the baseline level was abnormal and an absolute increase in serum bilirubin >2 mg/dl from baseline.


RESULTS
Sixty seven patients had confirmed TB with underlying cirrhosis and formed the study group. The mean age was 52 ± 12 years and M:F ratio was 57:10. Mean Child Turcotte Pugh (CTP) score 8.5 ± 1.5 (CTP A:B:C:7:44:16). The sites of TB included: pulmonary (25, 37%); pleural effusion (10, 16%) peritoneal (19, 29%); chest lymph nodes (3, 4%); liver (1, 1.5%); intestines (3, 4%), vertebra (3, 4%), brain (1, 1.5%) and disseminated (2, 3%). Thus, extrapulmonary TB was more common in the cirrhotic patients as compared to pulmonary TB. Patients with Child's status A (n = 7) received 4 drugs (R: rifampicin, H: Isoniazid, E: ethambutol, Z: pyrizinamide) and could tolerate well even during follow up without any drug induced toxicity. In rest of patients commonest regimen followed was combination of drugs (RHEO, n = 32) followed by RHE (n = 11). DILI occurred in 35% started with either RHEO, HEO and REO. Median time of onset of DILI was 12 days (4-34) days. There was no DILI related death during hospital stay or follow up.


CONCLUSIONS
Extrapulmonary TB is common in patients with cirrhosis and DILI is common in Child B and C with combination of rifampicin and isoniazid regimen.
Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.
Praveen
P
Sharma
Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.
Pankaj
P
Tyagi
Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.
Vikas
V
Singla
Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.
Naresh
N
Bansal
Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.
Ashish
A
Kumar
Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.
Anil
A
Arora
AST/ALT, Aspartate aminotransferase/alanine aminotransferase; ATT, Antituberculous therapy; CTP, Child Turcotte Pugh; DILI, Drug induced liver injury; E, ethambutol; H, Isoniazid; R, Rifampicin; TB, Tuberculosis; Z, pyrizinamide; cirrhosis; treatment; tuberculosis