Objective: Elevated liver enzymes with mild hepatic enlargement is frequently labeled as Non Alcoholic Steato Hepatitis (NASH) in type 2 diabetics. We report a case of 32 year old type 2 diabetic who was labeled as NASH and later found to have hepatic tuberculosis.
Case Presentation: A 32 year old non alcoholic patient with diagnosis as type 2 diabetes and NASH was referred to endocrinologist for poor glycemic control and non specific fatigue. On evaluation he was found to have HbA1C 8 percent, elevated ALT (55 U/L) and AST (50IU/L), low vitamin D3 (25 OH) (20ng/ml) and elevated ESR (50 mm/hr). USG abdomen showed fatty liver grade 1. Appropriate adjustment in oral anti diabetics, vitamin D and Vitamin E replacement along with reinforcement of diet and lifestyle measures was done. Follow up at 3 months revealed improvement in SMBG and HbA1C(7.2), normal AST, ALT and vitamin D levels but worsening fatigue, night sweats (euglycemic), and increased ESR (60 mm/hr). USG abdomen revealed altered hepatic architecture with portal vein dilatation and splenomegaly.
Further workup and liver biopsy revealed caseous necrosis and acid fast bacilli suggestive of hepatic tuberculosis. He was started on anti tubercular therapy and showed marked improvement in his symptoms.
Extra pulmonary tuberculosis is frequently reported in immunocompromised states like HIV infection. Chronic hyperglycemia is considered to be an immunocompromised state due to various mechanisms like depressed cellular immunity, macrophage dysfunction, low interferon gamma levels, microangiopathy, and micronutrient deficiency. Awareness of increased risk of infections is warranted in diabetics. In developing countries, the growing burden of diabetes can form an important link with tuberculosis, which is endemic here.
Conclusion: Organ dysfunction should be labeled with caution in diabetics. A high index of suspicion along with appropriate investigations can often lead to correct diagnosis.Biopsy still remains the gold standard and threshold of ordering it should be low whenever in doubt.
Jodhpur, Rajasthan, India
Consultant Endocrinologist and Diabetologist at Medipulse Hospital, Jodhpur. DNB Endocrinology from Apollo Hospital, New Delhi