Tuberculosis or Gallbladder carcinoma? A confusing presentation in an endemic region

Abstract

Introduction and importance

Gallbladder tuberculosis (GT) is an extremely rare clinical entity that represents only 1 % of abdominal tuberculosis cases. Preoperatively, most patients are misdiagnosed as chronic cholecystitis or gallbladder malignancy.

Case presentation

We report the case of a 43-year-old patient, whose clinic, imaging and biology were in favor of Gallbladder carcinoma.

Discussion

The clinical presentation of GT is varied and nonspecific, making the preoperative diagnosis of GT difficult; it may mimic acute cholecystitis to frank malignancy as seen in our case. Preoperatively, GT poses a diagnostic dilemma despite advanced imaging modalities, leading to missed diagnosis. The biology remains non-specific also. The diagnosis is usually made upon histological examination after cholecystectomy.

Conclusion

Even though the clinical presentation and the radiology are aspecific and misleading, It seems to us justified to evoke the diagnosis of tuberculosis faced with such a presentation, especially if the patient comes from a tuberculosis-endemic country. Diagnosis is made upon histopathological examination.

Highlights

• •Gallbladder tuberculosis is an extremely rare clinical entity.
• •we report the case of a 43-year-old patient, whose clinic, imaging and biology were in favor of Gallbladder carcinoma.
• •The diagnosis is usually made upon histological examination after cholecystectomy highlighting the importance of sending every gallbladder specimen to pathology.

1. Introduction

Over the last decade the world has witnessed a trend towards increasing numbers of people who have been infected with tuberculous (TB) infection [1]. Majority of these cases are found in middle and low income countries. Extra-pulmonary tuberculosis (EPTB) accounts for roughly 15 % of TB cases among immunocompetent hosts [2]. Gallbladder tuberculosis (GT) is an extremely rare clinical entity that represents only 1 % of abdominal tuberculosis cases [3]. Preoperatively, most patients are misdiagnosed as chronic cholecystitis or gallbladder malignancy [4,5]. Majority of reports describe patients presenting with constitutional symptoms such as fever, anorexia, weight loss and/or an underlying immunosuppressed state in patients with gallbladder TB. In this report, we present a case of isolated gallbladder TB mimicking gallbladder carcinoma in an immunocompetent patient with no significant past medical history. Our aim in this case is to warn clinicians, especially in endemic countries, never to forget GT as a differential diagnosis in all biliary tract disorders.

2. Case presentation

A 43-year-old man, operated 10 years ago for anal fistula, presented to the emergency department for acute abdominal pain in the right hypochondrium non-irradiating and without vomiting or other accompanying signs, that had persisted for 4 days. There was no history of fever, night sweats, cough with hemoptysis, unintentional weight loss or pulmonary tuberculosis. Abdominal examination revealed right hypochondrial tenderness, there was no scleral icterus and Murphy's sign was negative. There was no cervical lymphadenopathy. Physical examination was otherwise unremarkable. Laboratory investigations found an elevated white blood cells count (12,000/ml), C-reactive protein concentration was at (20 mg/l) and a very high level of cancer antigen 19-9 (2016 U/ml), liver function tests, including alcaline phosphatase were normal. Ultrasonography showed perivascular edema with thickened wall with polypoid content. A CT scan with intravenous contrast reported a suspicious irregular thickening of the gallbladder wall (Fig. 1). Bili-MRI also revealed an aspecific and irregular parietal thickening with a porcelain-like gallbladder wall (Fig. 2). The patient's file was submitted to a multidisciplinary consultation meeting and in view of the clinical picture, the radiological signs and the high level of cancer antigen 19–9, Surgical exploration of the presumptive diagnosis of GC was decided and done three days after admission. Intraoperatively, we found a hard gallbladder with a thickened wall and contiguous infiltration of the liver. The patient underwent radical cholecystectomy (Glenn operation). In the postoperative period, the patient was allowed oral intake on the second postoperative day (POD). Abdominal drain was removed on the third POD, and he was discharged on the fifth POD. Based on histological examination of the specimen, which showed an ulcerated mucosa surrounded by epithelioid cells mixed with rare giant Langerhans cells without caseous necrosis (Fig. 3) and the quantiferon levels that were above 0,34 IU/ml, the diagnosis of GT was retained. Antitubercular therapy with isoniazid (I), rifampicin (R), ethambutol (E), and pyrazinamide (P) for 6 months (intensive phase: 2 months of all 4 drugs and continuation phase: 4 months of E & P) was started. After the 9-month follow-up, he is doing well.

Fig. 1.

CT scan showing dense tissue formation filling the gallbladder without enhancement after injection of contrast product with perivascular infiltration.

Fig. 2.

Bili-MRI showing suspicious irregular thickening of the gallbladder wall.

Fig. 3.

Microphotograph showing an epithelioid cell granuloma with giant cells and early caseous necrosis.

3. Discussion

Hepatobiliary TB accounts for nearly 1 % of abdominal TB [3,6]. GT is uncommon because high alkalinity of bile and bile acids prohibit the growth of tubercle bacillus [7]. Only around 120 cases have been reported in the literature [3]. GT occurs most commonly in women over 30 years of age [3,8]. However, cystic duct obstruction causing low bile acid concentration and damage to the gallbladder mucosa predisposes to GT. TB can involve the gallbladder by hematogenous or lymphatic route from adjacent positive foci, by serosal spread from a peritoneal lesion or canalicular dissemination [7]. In the present case, the blockage of the cystic duct most likely predisposed to tubercular infection.

The rarity of tuberculosis in the gallbladder is possibly due to the hypovascularity of the gallbladder sac and the alkaline nature of gallbladder bile, which has an inhibitory effect on Mycobacterium [9].

The clinical presentation of GT is varied and nonspecific, making the preoperative diagnosis of GT difficult; it may mimic acute cholecystitis to frank malignancy as seen in our case [2,4].

Hence, GT should be considered as a differential diagnosis for gallbladder mass, especially in individuals from an endemic area or in an immunocompromised patient. The biology remains non-specific, some authors reported an elevation of liver enzymes in case of liver damage (found in 60 % of cases) [10].

Preoperatively, GT poses a diagnostic dilemma despite advanced imaging modalities, leading to missed diagnosis. Contrast-enhanced computed tomography imaging of GT may show thickened gallbladder wall, nodular lesion with homogeneous enhancement, calcific flecks, and necrosis [3]. The existing literature for biliary TB on magnetic resonance imaging (MRI) is scarce and mostly described as biliary strictures.

According to Govindasamy et al., the MRI morphology features of GT were identical to GC [11]. To summarize, there are no specific investigations for GT.

The diagnosis is usually made upon histological examination after cholecystectomy [9] highlighting the importance of sending every gallbladder specimen to pathology.

4. Conclusion

Gallbladder tuberculosis is an exceptional form of digestive tuberculosis. Even though the clinical presentation and the radiology are aspecific and misleading, It seems to us justified to evoke the diagnosis of tuberculosis faced with such a presentation, especially if the patient comes from a tuberculosis-endemic country. Diagnosis is made upon histopathological examination. A well-managed anti-tuberculosis treatment allows healing.

Abbreviations

GT

Gallbladder tuberculosis

TB

Tuberculosis

EPTB

Extra-pulmonary tuberculosis

CT scan

Computerized tomography scan

Bili-MRI

Biliary magnetic resonance imaging

GC

Gallbladder carcinoma

POD

Post-operative day

Methods

The work has been reported in line with the SCARE criteria.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Ethical approval

Ethics approval was provided by the ethical committee of Moulay Ismail military hospital (Nb 10/2023), Meknes, Morocco on 27 January 2023.

Funding

None.

Guarantor

The corresponding author is the guarantor of submission.

Research registration number

• Researchregistry.com

• researchregistry9282.

CRediT authorship contribution statement

Abdessamad El Kaoukabi, Mohamed Menfaa, Nizar Errabi and Hicham Krimou were responsible for the patient's diagnosis and clinical management. Abdessamad El Kaoukabi wrote the manuscript. The rest contributed to the analysis, supervision, writing, reviewing, and editing of the manuscript for intellectual content. All authors have read and approved the final manuscript.

Declaration of competing interest

The authors declare no conflict of interest.

Availability of data and materials

Supporting material is available if further analysis is needed.