Granulomatous hepatitis: tuberculosis or not?

The Medical Journal of Australia ISSN: 0025729X 4 February 2008 188 3 166-167 ©The Medical Journal of Australia 2008 www.mja.com.au Lessons from Practice can cause granulomatous hepatitis, tuberculosis (TB common. Hence, although the differential diagnosi main clinical decision related to the ability to diagno TB. If a patient with hepatic TB has corticosteroi erroneously diagnosed sarcoidosis, the conseque catastrophic. Active TB most typically presents wi symptoms, and the diagnosis can usually be made pr ra len pa G nulomatous hepatitis is an uncommon condition with a gthy list of possible causes, as shown in Box 1. In our tient, the biopsy did not show bile duct destruction characteristic of primary biliary cirrhosis, or any evidence of malignancy. The patient was not taking any drugs which could cause granulomatous hepatitis. The pathology laboratory report suggested the diagnosis was sarcoidosis, and, of the infections that ) is the most s is long, the se or exclude d therapy for nces may be th pulmonary ovided smears and cultures for mycobacteria are obtained. However, if a patient presents more atypically, as did our patient, clinicians may initially not suspect TB as the diagnosis. Tests used for the diagnosis of TB can be divided into two categories: the detection of a cell-mediated immune response to Mycobacterium tuberculosis (tuberculin skin test [TST] and QuantiFERON-TB Gold), and the detection of M. tuberculosis itself (by culture or polymerase chain reaction [PCR]). The TST is often falsely negative in immunosuppressed patients, and can give false-positive results if the patient has had previous BCG vaccination or infection with non-tuberculous types of mycobacteria. QuantiFERON-TB Gold is more specific for TB, but its sensitivity is poor, especially with immunosuppression. Both of these tests can be falsely negative in up to 20% of patients Clinical record