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LETTER TO EDITOR
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 337-338

“Tree-in-Bud” appearance in the liver in disseminated tuberculosis


Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission10-May-2022
Date of Decision19-Jun-2022
Date of Acceptance20-Jul-2022
Date of Web Publication12-Sep-2022

Correspondence Address:
Pankaj Gupta
Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_82_22

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How to cite this article:
Bhatia H, Gupta P. “Tree-in-Bud” appearance in the liver in disseminated tuberculosis. Int J Mycobacteriol 2022;11:337-8

How to cite this URL:
Bhatia H, Gupta P. “Tree-in-Bud” appearance in the liver in disseminated tuberculosis. Int J Mycobacteriol [serial online] 2022 [cited 2022 Sep 27];11:337-8. Available from: https://www.ijmyco.org/text.asp?2022/11/3/337/355928



Dear Editor,

Hepatic tuberculosis is usually seen as a part of disseminated disease.[1] Radiologically, there can be parenchymal or biliary involvement, with the latter being less common.

Parenchymal involvement can be divided into two forms: micronodular and macronodular.[2] Micronodular form is more common and is characterized by hepatosplenomegaly with subcentimeter-sized liver lesions on cross-sectional imaging. The macronodular form, on the other hand, usually presents as larger granulomas or abscesses that range from 1 to 3 cm in size, are hypodense on computed tomography (CT), are hyperintense on T2-weighted magnetic resonance imaging (MRI), and show peripheral contrast enhancement.[3]

Uncommonly, patients may also present with jaundice due to tubercular cholangitis, where biliary dilatation occurs either due to extrinsic compression by enlarged periportal lymph nodes or due to direct involvement of the biliary tree, leading to bile duct thickening and stenosis.[4]

Biliary involvement in such patients may show the “tree-in-bud” sign on cross-sectional imaging [Figure 1]. We describe one such case with disseminated tuberculosis who presented with abdominal pain and jaundice for 1 month. Clinical examination revealed hepatosplenomegaly. Ultrasonography revealed intrahepatic biliary dilatation, and thus, the patient was referred for a contrast-enhanced MRI (CEMRI).
Figure 1: A case of disseminated tuberculosis who presented with abdominal pain and jaundice for 1 month. (a) Axial contrast-enhanced magnetic resonance image showing a large necrotic periportal lymph node (arrow). There are multiple peripheral enhancing variable-sized liver lesions (thick arrows). (b) Magnetic resonance cholangiography image showing dilated biliary system (thick arrow) due to extrinsic compression by a lymph node (short arrow). Note multiple hyperintense lesions in close relation to the biliary radicle (arrows) giving “tree-in-bud” appearance

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CEMRI with magnetic resonance cholangiopancreatography (MRCP) showed multiple variable-sized T2-weighted hyperintense peripherally enhancing lesions in both lobes [Figure 1]a. MRCP showed biliary dilatation due to extrinsic compression by periportal lymph nodes. The branching pattern of the biliary tree with hepatic abscesses at branch points [Figure 1]b resembled classical “tree-in-bud” description on CT of the chest in patients with endobronchial tuberculosis.[5] This sign has not been previously described for tubercular biliary involvement.

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dhali A, Das K, Dhali GK, Ghosh R, Sarkar A, Misra D. Abdominal tuberculosis: Clinical profile and outcome. Int J Mycobacteriol 2021;10:414-20.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Kawamori Y, Matsui O, Kitagawa K, Kadoya M, Takashima T, Yamahana T. Macronodular tuberculoma of the liver: CT and MR findings. AJR Am J Roentgenol 1992;158:311-3.  Back to cited text no. 2
    
3.
Singh J, Dinkar A, Gupta P. Uncommon manifestations in tuberculosis: An expanding clinical spectrum from North India. Int J Mycobacteriol 2022;11:30-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Dhali A, Dhali GK, Ghosh R, Sarkar A. Primary tubercular granulomatous hepatitis presenting as fluctuating jaundice. Int J Mycobacteriol 2021;10:320-3.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Rossi SE, Franquet T, Volpacchio M, Giménez A, Aguilar G. Tree-in-bud pattern at thin-section CT of the lungs: Radiologic-pathologic overview. Radiographics 2005;25:789-801.  Back to cited text no. 5
    


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