Case Report Contrast-Enhanced Ultrasound LI-RADS LR-5 in Hepatic Tuberculosis: Case Report and Literature Review of Imaging Features Antonella Forgione 1,2 , Francesco Tovoli 1,2 , Matteo Ravaioli 2,3 , Matteo Renzulli 4 , Francesco Vasuri 5 , Fabio Piscaglia 1,2 and Alessandro Granito 1,2, *   Citation: Forgione, A.; Tovoli, F.; Ravaioli, M.; Renzulli, M.; Vasuri, F.; Piscaglia, F.; Granito, A. Contrast-Enhanced Ultrasound LI-RADS LR-5 in Hepatic Tuberculosis: Case Report and Literature Review of Imaging Features. Gastroenterol. Insights 2021, 12, 1–9. https://doi.org/10.3390/ gastroent12010001 Received: 7 December 2020 Accepted: 12 January 2021 Published: 17 January 2021 Publisher’s Note: MDPI stays neu- tral with regard to jurisdictional clai- ms in published maps and institutio- nal affiliations. Copyright: © 2021 by the authors. Li- censee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and con- ditions of the Creative Commons At- tribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna Via Albertoni 15, 40138 Bologna,Italy; antonella.forgione@studio.unibo.it (A.F.); francesco.tovoli2@unibo.it (F.T.); fabio.piscaglia@unibo.it (F.P.) 2 Department of Medical and Surgical Sciences, University of Bologna, Via Albertoni 15, 40138 Bologna, Italy; matteo.ravaioli@aosp.bo.it 3 Department of General Surgery and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy 4 Radiology Unit IRCCS Azienda Ospedaliero, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, 40138 Bologna, Italy; dr.matteo.renzulli@gmail.com 5 Pathology Division, IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40138 Bologna, Italy; francesco.vasuri@gmail.com * Correspondence: alessandro.granito@unibo.it Abstract: Background: The liver is involved in disseminated tuberculosis in more than 80% of cases while primary liver involvement is rare, representing <1% of all cases. Hepatic tuberculosis (TB) can be treated by conventional anti-TB therapy; however, diagnosing this disease remains a challenge. The diagnosis might be particularly difficult in patients with a single liver lesion that could be misdiagnosed as a tumor or other focal liver lesions. Although computed tomography (CT) and magnetic resonance imaging (MRI) findings have been described, there is a paucity of literature on contrast-enhanced ultrasound (CEUS) features of hepatic TB. Case Summary: herein, we describe a case of a patient with tuberculous lymphadenopathy and chronic Hepatitis C Virus (HCV)- related liver disease who developed a single macronodular hepatic TB lesion. Due to the finding of a hepatocellular carcinoma (HCC) highly suggestive CEUS pattern, specifically a LR5 category according to the Liver Imaging Reporting and Data System (LI-RADS), and a good response to antitubercular therapy, a non-invasive diagnosis of HCC was made, and the patient underwent liver resection. We also review the published literature on imaging features of hepatic TB and discuss the diagnostic challenge represented by hepatic TB when occurs as a single focal liver lesion. Conclusions: this report shows for the first time that the CEUS pattern of hepatic TB might be misinterpreted as HCC and specific imaging features are lacking. Personal history and epidemiological data are mandatory in interpreting CEUS findings of a focal liver lesion even when the imaging pattern is highly suggestive of HCC. Keywords: contrast-enhanced ultrasound (CEUS); Liver Imaging Reporting and Data System (LI- RADS); differential diagnosis; hepatocellular carcinoma (HCC); tuberculosis 1. Introduction Hepatic tuberculosis (TB) is more common in men than in women, with a 2:1 ratio. It affects mostly young patients in their second decade, although isolated hepatic TB is more common in 40- to 60 year-old patients than in younger patients. Around 15% of human immunodeficiency virus (HIV)-positive patients are co-infected with tuberculosis [1]. Diagnosing hepatic TB can be challenging since it can have different imaging patterns and patients might be asymptomatic or present with non-specific constitutional symptoms Gastroenterol. Insights 2021, 12, 1–9. https://doi.org/10.3390/gastroent12010001 https://www.mdpi.com/journal/gastroent