A 17-year-old male, resident of Nagpur, Maharashtra, India, a known case of MDR cervical lymph node tuberculosis on an all-oral longer MDR regimen, presented with gradually progressive yellowish discoloration of the eyes for 10-15 days, accompanied by pruritus, dark urine, and pale stools. The patient initially developed jaundice, followed by associated symptoms, while dull-aching right upper quadrant abdominal pain developed subsequently over the next five to six days, prompting further evaluation. There was no history of fever, vomiting, cough, hemoptysis, or weight loss.

On examination, the patient had icterus, with no clinical signs of hepatosplenomegaly or chronic liver disease. He also had a prior history of abdominal tuberculosis, for which he had received treatment for nine months.

Drug-induced hepatitis secondary to ATT was initially suspected, given its known association with ATT. However, the biochemical profile was more suggestive of a cholestatic pattern of liver injury rather than a hepatocellular pattern (Table 1). Viral hepatitis was considered as an alternative etiology but was excluded based on negative serological testing.

Differential diagnoses included drug-induced hepatotoxicity, cholangiocarcinoma, and obstructive pathology secondary to lymph nodal enlargement. Cholangiocarcinoma was considered less likely given the patient's young age and imaging features suggestive of a nodal mass rather than a primary biliary malignancy. Tuberculous lymphadenitis causing biliary obstruction was strongly suspected, supported by the clinical and radiological findings.

Histopathological confirmation was considered; however, due to the deep periportal location of the lesion and associated procedural risks, invasive biopsy was not pursued. The diagnosis was established based on clinical, biochemical, and radiological correlation.

The biochemical derangements indicated a cholestatic pattern of jaundice.

Imaging findings

Ultrasonography performed on 15/04/25 revealed hepatomegaly, with a liver span of 17.5 cm, along with dilated intrahepatic biliary radicals. The CBD and common hepatic duct (CHD) were also dilated, measuring 1.8 cm and 1.2 cm, respectively. A heterogeneous mass measuring 7 × 3.5 × 5 cm was identified adjacent to the pancreatic head and uncinate process (Figure 1).

Contrast-enhanced computed tomography (CECT) of the abdomen on 16/04/25 demonstrated a progressively enhancing periampullary and periportal mass, causing an abrupt, smooth cut-off of the CBD with significant upstream biliary dilatation (Figure 2). Based on imaging characteristics, the findings were suggestive of a tuberculous lymph nodal mass, and cholangiocarcinoma was considered unlikely.

Magnetic resonance cholangiopancreatography (MRCP) performed on 21/04/25 showed a coalescent lymph nodal mass involving the periportal, pericoeliac, and peripancreatic regions. This mass was compressing the mid-CBD, resulting in upstream biliary dilatation (Figures 3-4).

Overall, the imaging findings were consistent with obstructive jaundice secondary to lymph nodal tuberculosis.

Management

The diagnosis was confirmed after all laboratory and radiological investigations. ATT was temporarily withheld in view of severe cholestasis. Management of tuberculous lymphadenitis causing obstructive jaundice was started. The patient underwent percutaneous transhepatic biliary drainage (PTBD) to relieve CBD obstruction, resulting in rapid symptomatic improvement and reduction in bilirubin levels. Total bilirubin decreased from 15.1 mg/dL to 4.1 mg/dL following PTBD, with corresponding improvement in liver enzymes, indicating effective biliary decompression. Supportive therapy included ursodeoxycholic acid, hydration, and nutritional management.

After stabilization, the patient was restarted on an all-oral longer MDR regimen with careful monitoring of liver enzymes.

Follow-up ultrasonography (21/08/25) revealed a reduction in lymph node mass from approximately 7 × 3.5 cm to 3.5 × 5 cm, along with improvement in biliary dilatation.