|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 3 | Page : 337-338
“Tree-in-Bud” appearance in the liver in disseminated tuberculosis
Harsimran Bhatia, Pankaj Gupta
Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||10-May-2022|
|Date of Decision||19-Jun-2022|
|Date of Acceptance||20-Jul-2022|
|Date of Web Publication||12-Sep-2022|
Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
|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
Hepatic tuberculosis is usually seen as a part of disseminated disease. 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. 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.
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.
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. This sign has not been previously described for tubercular biliary involvement.
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