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King Edward Memorial Hospital Bombay, India
University of North Carolina School of Medicine Chapel Hill,
NC
Tuberculous abscesses of the liver are uncommon. The diagnosis is most often delayed or missed because of nonspecific symptomatology and rare occurrence. We describe imaging findings of a young patient with multiple tuberculous liver abscesses, abdominal lymphadenopathy, and inferior vena cava thrombosis.
A 28-old woman presented with a 2-week history of dull right-sided hypochondriac pain and moderate-grade fever. Her medical history was significant for pulmonary tuberculosis treated 5 years earlier. She was HIV negative. Clinical examination was noncontributory except for localized tenderness over the liver. Laboratory investigations revealed a high erythrocyte sedimentation rate (65 mm/hr), leukocytosis with polymorphonuclear predominance (WBC 10,000/µl; neutrophils 60%, lymphocytes 40%), raised alkaline phosphatase levels (319 U/l), and normal total bilirubin levels (11 g/l). Blood cultures had negative results. Chest radiography showed a right-sided loculated pleural effusion and a right lower zone parenchymal lesion. Abdominal sonography showed multiple septate hypoechoic lesions in the liver, abdominal lymphadenopathy, and segmental inferior vena cava thrombosis. Unenhanced and contrast-enhanced CT of the abdomen revealed multiple large hypodense (20 H) focal lesions in the liver that showed varying degrees of peripheral rim enhancement (Fig. 5). In addition, multiple large peripherally enhancing low-density lymph nodes were seen in peripancreatic, celiac, and retroperitoneal areas. Compression and thrombosis of the suprarenal segment of the inferior vena cava, a right-sided psoas abscess, and ascites were seen. Sonographically-guided aspiration of the liver abscesses yielded thick brown pus that did not grow pyogenic organisms. Trophozoites of Entamoeba histolytica were not seen. Although the Ziehl-Neelson stain for acid-fast bacilli was negative, Löwenstein-Jensen medium grew cultures of Mycobacterium tuberculosis. Percutaneous drainage of the liver and psoas abscesses was performed using 10-French pigtail drainage catheters (Cook, Bloomington, IN). The pigtail drainage catheter was removed after 10 days. The patient made a satisfactory recovery, and substantial reduction in the size of the lesions occurred after 6 weeks of antituberculous chemotherapy with four drugs (isoniazid, ethambutol, rifampicin, and pyrazinamide).
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The liver is an unusual target for formation of tuberculous abscesses. Approximately 100 cases have been described in the literature. CT findings of tuberculous abscesses described in the literature include hypodense focal lesions with or without ring enhancement on contrast administration [1]. Wilde et al. [2] reported a peculiar "honeycombed" septate pattern of tuberculous abscess. Differential diagnostic considerations include amebic or pyogenic abscesses and necrotic primary and metastatic neoplasms. Although the cluster sign was initially considered a specific sign of pyogenic abscesses, it has also been described in hepatic tuberculous lesions [3]. Thus, differentiation from other inflammatory and neoplastic conditions based on clinical and imaging characteristics is often difficult.
Liver tuberculosis is usually caused by pulmonary or intestinal tuberculosis. Although miliary-type lesions occur as a result of hematogenous spread, focal lesions are caused by bowel tuberculosis with spread via portal lymphatics. Secondary reactivation of the bacilli after hematogenous dissemination during primary infection is another mechanism by which the liver is affected. The diffuse form reflected in miliary tuberculosis predominates. The focal or nodular form presenting as tuberculoma or abscess is uncommon. Primary hepatic tuberculosis not associated with tuberculous foci anywhere in the body is rare, with fewer than 15 cases reported in the literature [1].
Clinical manifestations are frequently nonspecific and include weight loss, anorexia, fever, abdominal pain, and jaundice. Fever, hepatomegaly, right-sided hypochondriac pain, and icterus are usual clinical findings [1]. An increase in incidence of tuberculosis of the liver has occurred in patients with AIDS [4].
Precise diagnosis before surgery assists in instituting appropriate treatment. Percutaneous drainage of the abscess combined with antituberculous chemotherapy has been advocated by some studies [3]. Mustard et al. [5] treated tubercular liver abscess by local infusion of antitubercular drugs. Surgery is reserved for multiple large lesions and lesions refractory to medical treatment.
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