M is a 9 year old boy with a CD4 of 14 ( absolute count). He had always been thin but was apparently fairly well until about 6 months previously when he was admitted with pyelonephritis , then 2 months later he was admitted with gastroenteritis. On that admission he had a CXR that's reported to have "No lung or heart lesion. Bronchitic picture", an ESR of 129 and an abdominal ultrasound showed a 12mm pericardial effusion and intrahepatic duct dilation left lobe.Unfortunately no liver function tests were done and the diagnosis of TB doesn't seem to have been considered.

He then came to us 3 months later for ARV workup. He complained of weakness, poor appetite, and cough. CXR was normal, ESR had come down to 65 and he had actually gained a bit of weight. His baseline bloods showed a very high ALP and GGT: ALP iu/l 1582 ( 14xnormal) GGT iu/l 314 ( 6x normal ) ALT iu/l 44 (normal ) AST 104 (2-3 x normal ) FBC showed moderate anaemia (9.6) and a raised platelet count of 1077.

Repeat abdominal ultrasound again showed dilated intrahepatic ducts, and a smaller pericardial effusion of 8mm

A week later his GGT, and ALP had gone up further , as had his enzymes to a much lesser degree: ALP 2657 GGT 686 ALT 101 AST 194

His platelet count had come down to 550

Hep A IgM, Hep Bs Ag and AB and HCV IgG were all negative. IgM. INR was normal. His bilirubin has always been normal.

If I'd seen him initially I would probably have treated for TB on the basis of the ESR and pericardial effusion. I'm still tempted to do so, but the effusion is smaller and the ESR has come down without treatment and I don't want to exacerbate the liver problems

1)What is the differential diagnosis of his high ALP and GGT and his dilated intrahepatic ducts 2)Do you think we need to investigate it further before we start ARV's ? 3) if so, how ?. 4)How likely do you think TB is in this patient ? 5) What would be the danger of starting ART without investigating him further?