Tubercular liver abscess: a distinct entity not to be missed.

BACKGROUND: Liver abscess is fairly common in developing countries and its incidence is ever-rising. Though amoebic and pyogenic liver abscesses form majority of cases in our country, tubercular liver abscess (TLA) should also be considered as differential diagnosis. AIMS: To study the clinical and imaging profile of tubercular liver abscess while establishing its increased incidence. METHODS: A prospective observational study was carried out on 72 indoor cases of liver abscess, presenting to Department of Medicine, from November 2011 to February 2013. All cases were subjected to abscess tap and tapped abscess was sent for microbiological examination. RESULTS: Though amoebic liver abscess was most common type diagnosed, five cases came out to be tubercular (AFB positive). Mean age of TLA patients was 28.4 years (all males). All cases were sub-acute in presentation. Splenomegaly and ascites were noted in 60% and 40% cases respectively. ESR was raised in 80% cases with mean value of 52.8 mm at first hour. Haemoglobin was low in 80% cases. Serum Alkaline phosphatise (ALP) was raised in all cases, mean value being 1034.4 U/L. On ultrasonography, all abscesses were < 5 centimetres in size, most commonly involving seventh segment. They were multiple in numbers in 60% cases. All cases responded well to anti-tubercular treatment. CONCLUSIONS: Tubercular liver abscess has increased in incidence, and in majority of cases in our study, they were incidentally found with no associated foci of infection in lung or gastrointestinal tract. So, keeping high index of suspicion, TLA should be considered in all patients with subacute presentation and associated anaemia, splenomegaly or ascites. Also, TLA is associated with raised ESR and comparatively higher levels of ALP in serum. They are more commonly multiple in number on ultrasonography.

Tuberculous liver abscess in an immunocompetent adult male--a rare presentation.

A 20 year old young male was admitted to our hospital with complaints of pain in upper abdomen right side, anorexia and loss of weight. Ultrasonography of the upper abdomen revealed a hypoechoic area in the left lobe of liver. Entertaining the possibility of pyogenic or amoebic lesion, the patient was started on ofloxacin and metronidazole. Failing to get any response to the therapeutic intervention, ultrasound guided aspiration was undertaken. The aspirated pus did not grow any organism in pyogenic or fungal culture but showed acid fast bacilli in Z.N. stain. The treatment was shifted to four drugs ATT and there was dramatic improvement in the clinical condition. This case is being reported to emphasize that ruling out tuberculosis may avoid unnecessary delays in the initiation of specific anti-tubercular treatment. Also a greater awareness of this rare clinical condition may prevent unwarranted surgical intervention.