Isolated tuberculous liver abscess in an immunocompetent adult female

Swati Salila; Rakesh Kumar; Shailesh Kumar; Namrata Kumari; Anima Xess; Shivendra Kumar Shahi

CASE REPORT

Year : 2019 | Volume : 5 | Issue : 2 | Page : 173-174

Isolated tuberculous liver abscess in an immunocompetent adult female

Swati Salila¹, Rakesh Kumar², Shailesh Kumar³, Namrata Kumari⁴, Anima Xess⁴, Shivendra Kumar Shahi⁵
¹ Senior Resident, Dept. of Microbiology, AIIMS, Raipur, Chhattisgarh, India
² Associate Professor, Dept. of Microbiology, IGIMS, Patna, Bihar, India
³ Additional Professor, Dept. of Microbiology, IGIMS, Patna, Bihar, India
⁴ Professor, Dept. of Microbiology, IGIMS, Patna, Bihar, India
⁵ Professor and Head, Dept. of Microbiology, IGIMS, Patna, Bihar, India

Date of Submission	12-Jun-2019
Date of Acceptance	09-Jul-2019
Date of Web Publication	12-Aug-2019

Correspondence Address:
Anima Xess
Professor, Dept. Of Microbiology IGIMS
India

Source of Support: None, Conflict of Interest: None

Abstract

Tuberculosis ( TB ) is a common cause of morbidity and mortality worldwide. Extra-pulmonary tuberculosis is commonly associated with immune-compromised patient and is difficult to diagnose. Tuberculous liver abscess is rare even in endemic areas of Mycobacterium tuberculosis. An isolated tuberculosis is extremely rare and accounts for 0.3% of new TB cases. Here we report a rare case of isolated tuberculous abscess of liver in a young adult in an immune-competent female of 26 years.

Keywords: Mycobacterium tuberculosis, isolated tuberculous liver abscess, immune-competent

How to cite this article:
Salila S, Kumar R, Kumar S, Kumari N, Xess A, Shahi SK. Isolated tuberculous liver abscess in an immunocompetent adult female. J Indira Gandhi Inst Med Sci 2019;5:173-4

How to cite this URL:
Salila S, Kumar R, Kumar S, Kumari N, Xess A, Shahi SK. Isolated tuberculous liver abscess in an immunocompetent adult female. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Feb 5];5:173-4. Available from: http://www.jigims.co.in/text.asp?2019/5/2/173/301106

Background :

Tuberculosis (TB) is a common cause of morbidity and mortality worldwide which has alarmed government to initiate various national programmes for eradication of the disease. Tuberculous liver abscess is rare disease entity even in endemic areas of Mycobacterium tuberculosis. It is usually accompanied by pulmonary tuberculosis or tuberculous entero-colitis. An isolated tuberculous liver abscess is extremely rare.

Incidence of liver TB accounts for only 1.2% of all TB cases^[1]. Isolated hepatic TB accounted for 0.3% of new TB cases^[2]. In another study, tuberculous liver abscess occurred only in 0.24% of patients with hepatic TB. A study in 1990 indicated that only 13 cases of isolated liver abscess had been described in the English literature and less than 25 cases of isolated liver abscess has been documented prior to 2003^[3].

Case Report :

PRESENTING COMPLAINS - A 26 year old female from Bhagalpur district of Bihar visited our Out Patient Department (OPD) with complains of fever off and on with mild epigastric pain and abdominal fullness for the past one month. Patient also complained of loss of appetite, weakness and malaise. There was no complain of cough or dysuria or diarrhoea.

PAST HISTORY revealed that Patient was admitted in a local government hospital due to persistence of fever. Laboratory data showed marked leukocytosis, elevated ESR & CRP. Liver function tests were within normal limit. Viral markers were negative. Chest X-ray was normal. Ultrasonography and CT scan of the abdomen showed ill defined lesion in the left lobe of liver suggestive of neoplasia. Patient was referred to higher centre to rule out malignancy.

FAMILY HISTORY revealed that mother of the patient was suffering from pulmonary tuberculosis and hepatitis B Virus infection. She expired about two years back due to illness.

Physical Examination of the patient revealed that there was raised body temperature, mild tenderness in epigastric region and below right hypochondrium , bowel sounds were normal. Complete blood work up was done along with cancer markers i.e. CEA, CA19-9, AFP, which were not suggestive of malignancy.

Blood parameters showed: WBC count -17,000/mm3, Neutrophils - 82%, haemoglobin -7.5 g/dl, ESR - 72mm at 2hrs.CRP - 12.5mg/dl. Liver function test showed total bilirubin - 2.1mg/dl, Aspartate amino transferase ( AST)- 468 units/L, Alanine aminotransferase (ALT) -130 units/L, INR -2.01. Sodium- 135 mmol/L, Potassium -3.4 mmol/L, BUN- 9.6mg/dl, creatinine- 0.83 mg/dl. Viral markers for HBV, HCV and HIV were negative. Chest X-ray was within normal limits.

A computed tomography (CT) scan of the abdomen showed low density cystic mass in the left lob of the liver with suspecian of abscess. Ultrasound guided FNA was done and abscess was drained. Thick brown colour pus came out. Gram stain and Z N staining of the pus were done which were negative. Bacterial culture of the pus was done on Blood agar media and Mac-conkey agar media which did not show any significant growth. Finally Gene -Xpert Test was done with aspirated pus which confirmed presence of Mycobacterium tuberculosis and was sensitive to Rifampicin. The patient was immediately started on anti- tuberculous drugs as per RNTCP guideline for extrapulmonary TB . The pus was subjected to liquid culture for confirmation of presence of M. Tuberculosis which came positive. The patient responded well to the anti- tuberculous treatment as seen on follow-up.

Discussion :

Infection with Mycobacterium tuberculosis is common and affects one third of world’s population. It remains a major cause of death world -wide^[4]. TB most commonly affects the lungs. Extra-pulmonary sites of infection can affect any organ with most common sites being lymph nodes, pleura and osteo-articular areas. The diagnosis of extra pulmonary TB can be elusive and require a high index of suspicion^[5]. Hepato-biliary and pancreatic TB are rare and often associated with milliary TB occurring in immune compromised patients. The clinical presentation is nonspecific but may include anorexia, malaise, low grade fever, weight loss, night sweats, mass or abscess. Diagnosis of TB is difficult and often requires microbiological and histo- pathological examination^[6].

Hepatic TB is frequently seen in patient with disseminated TB. Miliary hepatic TB is rare and is often situated within lobules as the infection is thought to be carried from the gastrointestinal tract via portal vein^[7]. Three forms of hepatic TB have been described. The first is diffuse hepatic involvement, seen along with pulmonary or military TB. The second form is diffuse hepatic infiltration without pulmonary involvement, which was previously called primary military TB of the liver. The third is focal liver tuberculoma or abscess^[8].

Isolated hepatic TB is difficult to diagnose and invasive procedure is always needed. The past literature showed that exploratory laparotomy or autopsy led to the final diagnosis. Now biopsy is increasingly adopted. Although biopsy is less invasive, false negative results are possible, if the necrotic tissue is obtained instead of the margin of lesion. Differential diagnosis of abscess from the necrotic tumour is very important^[9].

The accepted criteria for diagnosis of hepatic TB include (1) Acid Fast Bacilli (AFB) in liver tissue, (2) tubercle bacilli elsewhere plus hepatic granulomas with or without caseation, (3) typical macroscopic appearance on laparotomy or peritoneoscopy and (4) response to anti- tuberculous therapy ^[10].

In our case - AFB was not found in Z N Staining of the sputum or pus aspirated from the liver. However with Gene-Xpert, it was possible to detect the presence of M. tuberculosis in the aspirated liver pus. Patient responded well to anti-tuberculous treatment. With the advent of newer techniques it is possible to establish diagnosis with lesser invasive method like FNA rather than laparotomy or peritoneoscopy. So, our case was of isolated tubercular liver abscess.

Primary tuberculous hepatic abscesses, with no evidence of infection elsewhere are uncommon. The diagnosis is often difficult to make and often made post-mortem^[11]. Primary involvement of the liver in TB is rare due to low tissue oxygen level which makes liver inhospitable for the bacilli^[12]. Imaging is helpful in identifying liver abscess, but it is not helpful in differentiating tuberculous liver abscess from other pyogenic liver abscesses.

Conclusion :

Isolated hepatic TB is extremely rare and high awareness is required to make a successful diagnosis. TB should be considered in patient from endemic areas or who do not respond to standard antibiotic therapy. Radiological findings have a low specificity and not helpful in making definitive diagnosis. However Gene-Xpert testing of pus from FNA is helpful in diagnosis of extra-pulmonary tuberculosis.

Percutaneous drainage is safe and effective treatment of liver abscess. Anti-tuberculous therapy is recommended in combination with abscess drainage in case of tuberculous liver abscess for effective treatment.

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