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Q J Med 1971; 40: 371-383
© 1971 Association of Physicians

research-article

Granulomatous Hepatitis of Obscure Aetiology

DIAGNOSTIC CONTRIBUTION OF KVEIM TESTING AND ANTI-TUBERCULOUS THERAPY

MUIRIS X. FITZGERALD, OLIVER FITZGERALD and ROBERT P. TOWERS

From St. Vincent's Hospital, Dublin, and Department of Medicine and Therapeutics, University College ‘Woodview’, Stillorgan Road, Dublin 4

Received 10 September 1970 Five unusual cases of granulomatous hepatitis are described. The diagnostic problems posed by each case are discussed in detail, specifically the difficulties encountered in establishing a firm aetiological factor even after comprehensive investigation.

Two patients with widely disparate clinical and pathological findings demonstrated a positive Kveim test. Despite thorough search, neither showed any clinical evidence of conventional sarcoidosis and in one case lymph-node histology was repeatedly negative for sarcoid granulomata. The significance of these cases and the current status of the Kveim tests are discussed. It is postulated that these two patients may fit into an expanding spectrum of conditions characterized by Kveim test positivity. This currently embraces: (i) sarcoidosis; (ii) Crohn's disease, both human and experimental; and (iii) ‘normal’ subjects who fail to convert tuberculin positivity after B.C.G. vaccination. To these we would add a number of patients with idiopathic granulomatous hepatitis. It is suggested that the Kveim test represents an histopathological expression of abnormal host reactivity common to a variety of conditions in which inter-related or cross-reacting antigens occur.

Although tubercle bacilli were not isolated, two further patients were adjudged to have hepatic granulomata of tuberculous origin on the basis of a suspicious clinical history and an unequivocal response to specific chemotherapy. In a third patient a trial of anti-tuberculous therapy obscured the true diagnosis of brucellosis for several years. The role of trials of anti-tuberculous therapy in cases of granulomatous hepatitis of unknown aetiology is discussed.


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