Diagnostic Challenge: Hepatic Granulomas Associated with FUO

A 35-year-old man living in Sistan was reffered to our center because of fever, night sweats, myalgia, fatigue and elevated Alk-P, ALT and AST from which he was suffering for 8 weeks.
He had no history of blood transfusion, IV drug abuse, systemic disease, or family history of hepatitis. He had not received any drugs for 3 months. He had a history of extramarital sexual contact 6 months before. Physical examination revealed hepatomegaly. There was no lymphadenopathy, rash, cough, icterus, and arthritis. He had lost 5 kilograms in weight.

Laboratory tests showed Hgb 12, WBC 10000, PMN 65%, lym 40%, Plt 200,000, ESR - 95, ALT 70, AST 65, Alk-P 700, GGT 650, total bilirubin 1.7, direct bilirubin 0.5, Wright (-), 2ME (-), VDRL negative , PPD test 8mm , anti-HIV negative, HBsAg negative, anti-HCV negative, anti-HAV IgM negative, CPK 40, LDH 370, anti-CMV IgM negative, EBV antiviral capsid IgM negative and angiotansine converting enzyme (ACE) normal. Three blood cultures after 3 weeks were sterile. Abdominal and chest CT scan were normal. The results of echocardiography and bone marrow biopsy were normal. A liver biopsy was performed. Examination of the smear revealed noncaseating granulomas with epithelioid cells. These were distributed randomly through parenchyma. A liver sample was referred for mycobacterium tuberculosis PCR test, the result of which was negative. Acid fast staining for tubercle bacilli was negative. A portion of the fresh biopsy specimen was sent for culture, and after 6 weeks, the result of the culture was negative.