J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://jmc.elmerpub.com

Case Report

Volume 17, Number 12, December 2026, pages 727-732

Prolonged Cholestasis as an Initial Presentation of Miliary Tuberculosis in a Pediatric Patient

↓ Figure 1. Liver biochemical profile with elevated aminotransferases and cholestatic enzymes. AST: aspartate aminotransferase; ALT: alanine aminotransferase; GGT: gamma-glutamyl transferase.

↓ Figure 2. Baseline chest X-ray and CT. (a) Bilateral thickening of the peribronchovascular parahilar interstitium with consolidation in the upper lobe and lingula. (b) Chest computed tomography with multilobar involvement characterized by bilateral ground-glass opacities, peripheral micronodules, and alveolar filling regions. CT: computed tomography.

↓ Figure 3. Liver biopsy (a) Multiple granulomas in the liver parenchyma (arrows, H&E, × 10). (b) Granuloma with peripheral halo of lymphocytes, central necrosis, and presence of multinucleated giant cells (arrows, H&E, × 40). H&E: hematoxylin and eosin stain.

↓ **Table 1.** Approach to Prolonged Neonatal Cholestasis in a 2-Month-Old Infant
Diagnostic study	Result
CMV: cytomegalovirus; EBV: Epstein–Barr virus; HIV: human immunodeficiency virus; COVID: coronavirus disease; TSH: thyroid-stimulating hormone; T4: thyroxine; ANAs: antinuclear antibodies; anti-LKM1: anti-liver-kidney microsomal type 1 antibody; ANCA: antineutrophil cytoplasmic antibodies.
First line studies
Intraoperative cholangiography	Negative for biliary atresia
Infectious disease screening	Negative: hepatitis A, B, CMV, EBV, HIV, COVID, Toxoplasma, rubella, HSV, adenovirus
Alpha-1 antitrypsin level	288 mg/dL (90–200), normal
Thyroid profile	TSH 6.45 µU/mL; free T4 1.83 ng/dL
Alagille syndrome workup	No butterfly vertebrae, no cardiopathy, no ocular alteration, no dysmorphic facies, no renal involvement
Second line studies
Immunologic workup	Normal immunoglobulins, normal neutrophil burst
Metabolic workup	Qualitative amino acids in urine: normal; very long-chain fatty acids: elevated C26:1-hexacosenoic (elevated in malnutrition); blood gases: normal; ammonia 68.8 µg/dL
Autoimmune hepatitis and vasculitis workup	Negative ANAs, negative anti-smooth muscle antibody, negative anti-LKM1, immunoglobulin G 917 mg/dL, negative ANCA
Total bile acids	140.99 µmol/L, elevated
Iontophoresis with pilocarpine stimulation	First: 52 mEq/L (indeterminate); Second: 31 mEq/L (associated with probable malnutrition)
Genetic study	Whole-exome sequencing (WES) and mitochondrial genome single-copy number variant screening: negative

↓ Table 1. Approach to Prolonged Neonatal Cholestasis in a 2-Month-Old Infant

Diagnostic study

Result

CMV: cytomegalovirus; EBV: Epstein–Barr virus; HIV: human immunodeficiency virus; COVID: coronavirus disease; TSH: thyroid-stimulating hormone; T4: thyroxine; ANAs: antinuclear antibodies; anti-LKM1: anti-liver-kidney microsomal type 1 antibody; ANCA: antineutrophil cytoplasmic antibodies.

First line studies

Intraoperative cholangiography

Negative for biliary atresia

Infectious disease screening

Negative: hepatitis A, B, CMV, EBV, HIV, COVID, Toxoplasma, rubella, HSV, adenovirus

Alpha-1 antitrypsin level

288 mg/dL (90–200), normal

Thyroid profile

TSH 6.45 µU/mL; free T4 1.83 ng/dL

Alagille syndrome workup

No butterfly vertebrae, no cardiopathy, no ocular alteration, no dysmorphic facies, no renal involvement

Second line studies

Immunologic workup

Normal immunoglobulins, normal neutrophil burst

Metabolic workup

Qualitative amino acids in urine: normal; very long-chain fatty acids: elevated C26:1-hexacosenoic (elevated in malnutrition); blood gases: normal; ammonia 68.8 µg/dL

Autoimmune hepatitis and vasculitis workup

Negative ANAs, negative anti-smooth muscle antibody, negative anti-LKM1, immunoglobulin G 917 mg/dL, negative ANCA

Total bile acids

140.99 µmol/L, elevated

Iontophoresis with pilocarpine stimulation

First: 52 mEq/L (indeterminate); Second: 31 mEq/L (associated with probable malnutrition)

Genetic study

Whole-exome sequencing (WES) and mitochondrial genome single-copy number variant screening: negative