Primary tubercular liver abscess rupture leading to parietal wall abscess: A rare disease with a rare complication

G Gupta, S Nijhawan, P Katiyar, A Mathur 
 Department of Gastroenterology, SMS Medical College and Hospital, Jaipur, Rajasthan, India

Correspondence Address:
G Gupta
Department of Gastroenterology, SMS Medical College and Hospital, Jaipur, Rajasthan
India

Full Text

Sir,

Tuberculosis presenting solitary, as liver abscess is rare and the prevalence of tubercular liver abscess is 0.34% in patients with hepatic tuberculosis. [1]

A 35-year-old woman presented with continuous dull pain in the right hypochondrium, anorexia and weight loss for 5 months. Physical examination revealed a tender, cystic, fluctuant lump 5×5 cm on the right anterior lower chest wall extending to upper abdominal wall. Investigations showed hemoglobin 7.8 gm/dl; total leukocyte count 7290/mm 3 ; erythrocyte sedimentation rate 52 mm/h; total bilirubin 0.7 mg%; serum alkaline phosphatase 107 IU; AST 23 IU; ALT 107 IU; serum protein 7.7 g/dl and serum albumin 3.9 g/dl. HIV serology was negative. Chest X-ray was normal. Ultrasonography (USG) of the abdomen revealed two cystic space occupying ill-defined, heterogeneous hypo-echoic lesions both measuring 3×3 cm and one solid lesion measuring 2.5×3 cm in the right lobe of liver. Contrast-enhanced computed tomogram of abdomen revealed a hypodense peripherally enhancing lesion measuring 2.8×3.2 cm in the right lobe of the liver communicating with the subcapsular lesion and parietal wall abscess [Figure 1] and [Figure 2]. USG guided FNAC revealed epithelioid granulomas, caseation necrosis and occasional langhans giant cells [Figure 3]. No acid-fast bacilli were detected. PCR of the aspirate was positive for M. tuberculosis. Patient was treated with four drug anti-tubercular therapy (ATT) and showed symptomatic response and on follow up after 5 months hepatic lesions resolved [Figure 4].{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Hepatobiliary tuberculosis is classified as Miliary, granulomatous, and localized. [2] Primary localized involvement as a tuberculous abscess alone is rare. Clinical manifestations of tubercular liver abscess are nonspecific. Common complaints include vague/localized right upper quadrant pain, fever, and anorexia. Ruptured tubercular liver abscess presenting as a parietal wall swelling is an extremely rare presentation. There are two similar case reports, one had liver abscess ruptured in chest wall [3] and another in abdominal wall. [4]

Accurate diagnosis is often delayed and high index of suspicion is required for diagnosis and is commonly misdiagnosed as malignancy, pyogenic, and amoebic liver abscess.

Radiologic examination is a useful tool to diagnose hepatic tuberculosis. Plain radiographs may show hepatic calcifications and concomitant pulmonary tuberculosis in 10-86% of cases. [5] USG and computed tomography (CT) will detect masses, their extent and local complications. Etiological diagnosis requires tissue sampling by FNAC or biopsy and diagnosed by characteristic granuloma±caseation necrosis and presence of AFB, culture or PCR. Except for PCR which has sensitivity up to 100%, [6],[7] all other methods have low sensitivity. Some clinicians accept a good response to ATT as an evidence of tuberculosis, but this approach may waste the crucial time especially in malignancy; hence, this should be deferred in the present era of modern diagnostics. These cases should be treated with ATT under category I of DOTS.

Therefore, one should keep possibility of tubercular etiology in case of liver abscess with indolent course and TB-PCR is an important tool for its diagnosis.

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