We present a rare case of a 46-year-old man who presented with recurrent fever and abdominal pain without other symptoms. Laboratory data were no specific for diagnosis. Abdominal imaging revealed a pseudotumor liver. A diagnosis of isolated liver tuberculosis with abscess component was confirmed with US-guided liver biopsy and histopathological examination. The patient received antibacillous drugs with success.
Tuberculosis is one of the most common diseases in Morocco
A 46 year old man was admitted with 5 months history of remittent fever ranging between 37.6°C and 38.2°C. The fever was associated with chills and epigastric pain, as well as night sweats. The patient has also a history of 10 Kg weight loss along with loss of appetite. On clinical examination, the patient was, oriented in time and space, cooperative, febrile 37,9, anicteric and normopneic, without peripheral lymphadenopathy. He had abdominal tenderness in the epigastric region, without hepatosplenomegaly.
Laboratory analysis showed hemoglobin, 10.9 g/dL; white blood cell count, 9,800 cells/mm3, serum albumin, serum total bilirubin, alanine aminotransferase, aspartate aminotransferase, prothrombin time, hepatitis B surface antigen, and antibodies to hepatitis C, serum alpha-fetoprotein (AFP), carcinoembryonic antigen and carbohydrate antigen 19-9 (CA 19-9) were within normal range. Blood cultures were negative. Chest x-ray was normal. Ultrasound of abdomen showed a 10 cm hypoechogenic lesion in left liver (
Tuberculosis is a health problem in the developing countries
Diffuse hepatic involvement with pulmonary or miliary tuberculosis is the most frequent forms in hepatic tuberculosis. The second common form is granulomatous hepatitis. It is a diffuse hepatic infiltration without pulmonary involvement. In our patient the lesion was a pseudotumor of the liver and presents the third form as a focal local tuberculoma or abscess
Tuberculosis spreads to the liver through the hepatic artery, the portal system and the lymphatic system. It commonly involves the hepatic parenchyma and sometimes the biliary tree
Imaging is useful for diagnosis. Abnormal chest x-rays demonstrating pulmonary tuberculosis can help for diagnosis. Our patient presented with no evidence of active pulmonary disease and the ultrasonography showed a hypoechoic rim and solitary lesion. In theses cases, it is difficult to differentiate them from carcinoma
Computed tomography (CT) and magnetic resonance imaging (MRI) are helpful in diagnosis.
CT findings of tuberculosis abscesses can show low-density focal lesions with or without ring enhancement on contrast administration. These have also been seen in necrotic tumor such as hepatocellular, inflammatory disease and metastatic carcinoma
CT-guided aspiration and biopsy can confirm the diagnosis. Percutaneous needle biopsy of the liver using ultrasound, CT has greater than 90 percent sensitivity. In case of pseudotumor tuberculosis mimicking a carcinoma, the role of biopsy is important because it can change therapeutic attitudes. The definitive diagnosis of this disease is conventionally made by histological analysis of caseating granuloma or demonstration of acid-fast bacilli on culture of biopsy specimen
Otherwise, the rate of accurate pretreatment diagnosis by guided percutaneous liver biopsy has been reported to be low, and the presence of tubercle bacilli in the biopsy sample is rare. In these cases, using polymerase chain reaction to directly detect the presence of Mycobacterium tuberculosis improves sensitivity rates
CT drainage is good for the successful drainage of tubercular abscess, although surgical drainage may occasionally be required
The treatment of hepatobiliary tuberculosis does not differ from other extrapulmonary tuberculosis. We usually use Chemotherapy with standard anti-tuberculosis drugs. This is true for both diffuse as well as the local forms of the disease. In general, a 6- to 9-month regimen (2 months of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol followed by 4–7 months of isoniazid and rifampin) is the recommended treatment for extrapulmonary tuberculosis
The surgical treatment is most often indicated when a diagnosis of liver tumor is assumed. In these cases therapeutic modalities include all kinds of hepatic resection with postoperative administration of antituberculous agents
The prognosis remains excellent with appropriate antibacillous treatment. The Mortality rate for hepatic tuberculosis is higher in immunodeficient patient. Predictive factors of mortality are age under 20 years, miliary tuberculosis, concurrent steroid therapy, AIDS, cachexia, associated cirrhosis and liver failure
Liver tuberculosis is a rare and curable disease. The clinical presentation of isolated liver tuberculosis is non-specific. Preoperative diagnosis when it presents, as pseudotumor lesions are difficult. Histopathology is necessary for diagnosis. Because of the increasing incidence of tuberculosis, clinicians should be aware of the possibility of tuberculosis disease with liver pseudotumor.
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