Acute liver failure as a rare presentation of miliary tuberculosis with clinical improvement following prediagnostic corticosteroid therapy: A case report

We report a rare case of miliary tuberculosis presenting as acute liver failure in a 72-year-old man with end-stage renal disease on maintenance hemodialysis. The patient was initially treated for septic shock due to suspected acute cholangitis and was administered hydrocortisone. However, endoscopic retrograde cholangiopancreatography revealed no biliary obstruction. Despite stabilization, liver failure progressed, accompanied by coagulopathy, thrombocytopenia, and hyperbilirubinemia. Elevated ferritin and soluble interleukin-2 receptor levels raised concerns of lymphoma or virus-associated hemophagocytic syndrome. Prediagnostic corticosteroid pulse therapy was initiated on day 4, leading to improvement in liver function and hematologic parameters. Liver biopsy on day 8 revealed scattered noncaseating epithelioid granulomas with Langhans giant cells. Mycobacterium tuberculosis was detected by polymerase chain reaction of sputum and urine, and confirmed by positive sputum and blood cultures. A four-drug antituberculous regimen was initiated on day 18. This case underscores that miliary tuberculosis can present as acute liver failure and mimic biliary sepsis. When cholangitis is unsubstantiated, performing liver biopsy is crucial. Additionally, corticosteroid therapy may provide clinical benefit in miliary tuberculosis complicated by liver failure or shock, regardless of the timing of antituberculous treatment.