A 68-year-old male was admitted in our in-patient ward with a history of low-grade fever for 2 months, epigastric pain with episodic nausea and vomiting, anorexia and history of unintentional weight loss. He was diagnosed with pulmonary tuberculosis thirty years back and had taken a full course of antitubercular drugs. He denied the use of tobacco products, alcohol, or any other illicit drugs. Similarly, he had no history suggestive of any high-risk behavior.
On examination, he was conscious, well oriented in time, place, and person. He was febrile with other vital parameters within the normal range. He did not have clubbing, edema, or palpable lymph nodes. He had a nontender hepatomegaly but no splenomegaly. Respiratory and cardiovascular system examination was essentially normal in this patient.
He had hemoglobin level of 10.1 g/dL (normal: 13.3-16.2 g/dL) and total leukocyte count of 6500/mm3 (normal: 4000-11000/mm3). Erythrocyte sedimentation rate was 70 mm in the first hour (normal: 0-20 mm in the first hour, Wintrobe's method). Kiney function test was normal. Liver functions tests (LFT) showed a total bilirubin of 1.4 mg/dL (normal: 0.3-1.2 mg/dL), serum alkaline phosphatase (ALP) of 290 U/L (normal: 40-280 U/L), aspartate aminotransferase (AST) of 132 U/L (normal: 12-38 U/L), alanine aminotransferase (ALT) of 181 U/L (normal: 7-41 U/L). Ultrasonography (US) of the abdomen revealed a large heterogeneously hypoechoic lesion with internal echoes in the segment six of liver suggestive of abscess (Fig.1). A contrast-enhanced computerized tomographic (CT) scan of abdomen also revealed abscess in the right lobe of liver (Fig2). There was no significant mesenteric, retroperitoneal, or pelvic lymphadenopathy with no other focal lesion. No perihepatic or pleural effusion was seen. All other abdominal viscera appeared normal with no free fluid.
He was started on intravenous Ceftriaxone and Metronidazole. His clinical conditions did not improve even after 1 week of treatment. A follow-up US showed no reduction in the size of the abscess. Under US guidance, a pig-tail catheter was inserted, and around 100 mL of thick cream colored fluid was aspirated. The fluid was negative for any gram positive or negative bacteria. Fungal stain was also negative. Ziehl-Neelsen staining of the specimen showed Mycobacterium tuberculosis (MTB) in the specimen (Fig.3). Contrast-enhanced CT of the chest had signs of old pulmonary tuberculosis but none of active tuberculosis. Sputum as well as broncho-alveolar lavage fluid stain for acid-fast bacilli (AFB) as well as Gene-expert for MTB were negative. The patient was nonreactive in HIV serology. The diagnosis of primary TLA was made.
As he had a history of pulmonary tuberculosis, TLA was considered as a relapsed form of tuberculosis. With that consensus, he was started on systemic antitubercular treatment (ATT) of twelve months duration, and this included isoniazid (300 mg once daily), rifampicin (450 mg once daily), pyrazinamide (1200 mg once daily), ethambutol (750 mg once daily), intramuscular streptomycin (750 mg once daily), and pyridoxine (20 mg once daily) which was to be continued for 2 months. After 2 months, the patient was instructed to take all the drugs, other than Streptomycin for 2 more months. For the remaining last 8 months, the patient was instructed to take rifampicin (450 mg once daily) and isoniazid (300 mg oncle daily) with pyridoxine (20 mg once daily). The patient improved significantly within 1 week of initiation of ATT with normalization of his biochemical parameters. He was then discharged with periodic follow-up plans.
At the follow-up visit after 4 months, the patient was asymptomatic, his liver size had decreased and a repeat US of abdomen revealed regression of the abscess. He was free of adverse drug effects like drug-induced hepatitis (common with isoniazid and rifampicin), gastro-intestinal upsets (common with rifampicin), or symptoms suggestive of peripheral neuropathy (common with isoniazid). The patient will be under our observation till he finishes the complete course of ATT.