Diagnostic Value of Percutaneous Liver Biopsy in Fever of Unkown Origin in Patients with Human Immunodeficiency Virus Infection

Abstract

SUMMARY: Fever of unknown origin (FUO) poses a major diagnostic challenge in patients infected with human immunodeficiency virus (HIV). In this retrospective study, we sought to assess the clinical utility of percutaneous liver biopsy as a diagnostic aid for FUO in HIV-infected patients and identify the factors associated with a greater likelihood of a positive diagnostic yield form this procedure. A total of 101 HIV-infected patients with FUO, who had undergone percutaneous liver biopsy in an HIV care hospital, served as the study population. The results obtained from percutaneous liver biopsy were categorized into three groups: (i) diagnostic, (ii) helpful, and (iii) not helpful. Diagnostic and helpful results were classified as useful. The mean (SD) age of patients was 37.6 (6.9) years, and the median (interquartile range [IQR]) CD4 count was 18 (3-62) cells/mm 3 . The median (IQR) duration of fever was 20 (8-30) days. Percutaneous liver biopsy was diagnostic in 51 patients (50.5z), helpful in 12 (11.9z) and not helpful in 38 (37.6z) patients. On multivariate analyses, elevation of serum alkaline phosphatase level (OR 1.27 per one time elevation from the upper normal range; 95z CI, 1.03-1.57; P ＝ 0.023), and fever duration of less than 3 weeks (OR 3.82; 95z CI, 1.03-14.18; P ＝ 0.046) was significantly associated with the likelihood of the biopsy findings being classified as useful. Our study supports the case for percutaneous liver biopsy as a useful diagnostic aid in HIV-infected patients with FUO.

Liver Biopsy: To Do or Not to Do – A Single-Center Study

“…In the setting of FUO, 5 out of 7 biopsies failed to reach a diagnosis; the other two revealed liver infiltration from Hodgkin's lymphoma and drug-induced hepatitis. Our study agrees with studies previously published showing a high percentage of unhelpful PLBs in patients suffering from FUO, with only about 15% of them helping reach a diagnosis, a percentage that increases in human immunodeficiency virus-infected individuals [44][45][46][47]. However, having in mind that almost 20% of patients with FUO remain undiagnosed even after rigorous investigation, PLB is still considered a useful tool in the investigation of FUO, particularly when accompanied by significant transaminasemia or hepatomegaly [48].…”

British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical investigation and management of pyrexia of unknown origin 2023

“…Of nine relevant studies on the use of liver biopsy in the investigation of PUO among people living with HIV, eight were single-centre observational studies [46][47][48][49][50][51][52][53]. The ninth was the comparison by Prego et al [45], discussed above, of mycobacterial blood culture, liver biopsy and bone marrow biopsy among 12 individuals in the pre-ART era.…”

“…The eight single-centre studies evaluated a total of 356 individuals with HIV and PUO, from settings across Europe, North America, East Africa and South East Asia, and were published between 1990 and 2015. Quality of evidence for individual studies was very low, but some results were similar across studies [46][47][48][49][50][51][52][53].…”

“…Four studies showed that mycobacterial infection was more frequently identified among those with raised alkaline phosphatase levels [46][47][48][49]. In one of these studies, conducted in Spain, in which the predominant diagnoses were TB and visceral leishmaniasis, liver biopsy was found to be helpful in the presence of hepatomegaly or splenomegaly and, for those with TB, in the presence of hepatomegaly and raised alkaline phosphatase [48].…”

“…Diagnoses other than mycobacterial infection, made by liver biopsy, included: leishmaniasis, cryptococcal disease, schistosomiasis and lymphoma in the two above-mentioned studies from France [50,51]; cytomegalovirus disease, malignancy and bacillary angiomatosis in the above-mentioned study from Thailand [46]; and cytomegalovirus, lymphoma and schistosomiasis in a study from New York [52].…”