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LETTER
Year : 2011  |  Volume : 57  |  Issue : 4  |  Page : 350-352

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


Department of Gastroenterology, SMS Medical College and Hospital, Jaipur, Rajasthan, India

Date of Web Publication22-Nov-2011

Correspondence Address:
G Gupta
Department of Gastroenterology, SMS Medical College and Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.90095

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How to cite this article:
Gupta G, Nijhawan S, Katiyar P, Mathur A. Primary tubercular liver abscess rupture leading to parietal wall abscess: A rare disease with a rare complication. J Postgrad Med 2011;57:350-2

How to cite this URL:
Gupta G, Nijhawan S, Katiyar P, Mathur A. Primary tubercular liver abscess rupture leading to parietal wall abscess: A rare disease with a rare complication. J Postgrad Med [serial online] 2011 [cited 2019 Nov 12];57:350-2. Available from: http://www.jpgmonline.com/text.asp?2011/57/4/350/90095


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: CECT abdomen (axial image) showing peripheral enhancing hypodense lesion in the right lobe of liver communicating with subcapsular lesion and rupturing in to parietal wall

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Figure 2: CECT abdomen (reconstructed saggital and coronal images) showing peripheral enhancing hypodense lesion in the right lobe of liver ruptured in anterior abdominal wall and lower chest wall

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Figure 3: Photomicrograph showing epitheloid granuloma with caseation necrosis in the background. The inset shows a langhans giant cell (H and E, ×40)

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Figure 4: CECT abdomen (axial view) showing resolution of hepatic lesion after antitubercular therapy

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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.

 
 :: References Top

1.Essop AR, Segal I, Posen J, Noormohamed N. Tuberculous abscess of the liver. A case report. S Afr Med J 1983;6:825-6.  Back to cited text no. 1
    
2.Alvarez SZ. Hepatobiliary tuberculosis. J Gastroenterol Hepatol 1998;13:833-9.  Back to cited text no. 2
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3.Mohanty D, Jain BK, Gupta A, Agrawal V. Chest wall abscess: An atypical presentation of isolated tuberculous liver abscess. Acta Biomed 2009;80:77-9.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Desai N, Patil S, Thakur BS, Das HS, Manjunath SM, Sawant P. Abdominal wall abscess secondary to subcapsular tubercular liver abscess. Indian J Gastroenterol 2003;22:190-1.  Back to cited text no. 4
[PUBMED]    
5.Huang WT, Wang CC, Chen WJ, Cheng YF, Eng HL. The nodular form of hepatic tuberculosis: A review with five additional new cases. J Clin Pathol 2003;56:835-9.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Diaz ML, Herrera T, Vidal YL, Calva J, Hernandez R, Palacios GR, et al. Polymerase chain reaction for the detection of Mycobacterium tuberculosis DNA in tissue and assessment of its utility in the diagnosis of hepatic granulomas. J Lab Clin Med 1996;127:359-63.  Back to cited text no. 6
    
7.Huang WT, Wang CC, Chen WJ, Cheng YF, Eng HL. The nodular form of hepatic tuberculosis: A review with five additional new cases. J Clin Pathol 2003;56:835-9.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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