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THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 13 CASE REPORT Introduction Tuberculosis (TB) is common in South Africa but tuberculous liver abscess (TLA) is extremely rare entity with a prevalence of 0.35% of patients with hepatic TB. 1 Less than 25 cases were reported in the literature prior to 2003. Focal TB of the liver can be manifested by single or multiple tuberculous abscesses. 2 These occur more frequently in immunocompromised patients and are associated with foci of infection in the lung and or gastrointestinal tract. 3 We describe a case of focal TLA in a patient with type 2 diabetes mellitus (DM). Case presentation A 57-year-old male known with type 2 DM, hypertension presented with 2-month history of progressive right upper quadrant (RUQ) pain, vomiting, fever, chills and rigors. He had weight loss of approximately 20kg. On examination he was pale but no jaundice or lymphadenopathy. Abdominal examination revealed point tenderness over the liver. There was no splenomegaly, ascites or palpable mass. Respiratory exam revealed a right pleural effusion. Investigations revealed a white cell count 12.42x 109/L, erythrocyte segmentation rate >140mm/hr, liver function tests were normal except for raised alkaline phosphatase 419 U/L and gamma glutamyl transferase 207 U/L. Human immunodeficiency virus, amoebic and hydatid serology were negative. Abdominal ultrasound showed a large cystic mass (7.5cm x 8.2cm x 9.6cm) with ill-defined borders and internal hypoechoic components in segment VI of the liver. Pus was aspirated under ultrasound guidance and sent for cytology and microbiological investigation. Polymerase chain reaction testing (GeneXpert) and culture were negative for TB while cytology showed multiple acid-fast bacilli (AFB) on Ziehl-Neelsen staining. Pleurocentesis done showed an exudative effusion with no acid-fast bacilli, GeneXpert & TB culture were negative. A diagnosis of TLA was made and the patient commenced on standard intensive phase four drugs anti-tuberculous treatment. Percutaneous drainage of the liver abscess was done. Review after two months confirmed resolution of clinical symptoms; he had gained weight with no RUQ tenderness. Abdominal ultrasound showed resolution of focal liver lesion /no evidence of recollection. There was resolution of the pleural effusion. He completed 6 months of anti-TB treatment. Discussion Hepatic TB is an uncommon form of extrapulmonary TB reported in 10-15% of patients with extrapulmonary tuberculosis with TLA being rare with a prevalence of 0.35%. 4 Tubercular liver abscess is usually secondary to tuberculosis of the lung or gastrointestinal tract, where these bacilli reach liver by haematogenous spread. 4 Focal TB of the liver can be manifested by a single or multiple tuberculous abscesses. 5 Symptoms are mostly non-specific with high grade fever, RUQ pain and hepatomegaly the most frequently observed clinical findings while jaundice is uncommon. 3,4 Although TLA is rare it can be considered as a differential diagnosis of amoebic liver abscess, pyogenic liver abscess and hepatoma. Radiological findings are non-specific and definitive diagnosis is confirmed by demonstration of tubercular bacilli in aspirated pus or liver biopsy stained for AFB, culture or GeneXpert for mycobacterium. 3 Ziel -Neelsen staining is an affordable technique but lacks sensitivity for mycobacterium. Mycobacterium tuberculosis culture is the gold standard for diagnosis but requires viable microorganism and long incubation period. 7 Polymerase chain reaction assay of both pulmonary and extrapulmonary specimens had a good sensitivity (92%) and high specificity (98%) in one study. 8 In some cases diagnosis is based on response to empirical anti-TB treatment. In a case report by Devi et al., all the conventional tests were negative but cytology was positive for AFB and this was similar to our case. 9 Management include anti-tuberculosis drugs alone or in combination with percutaneous aspiration under ultrasound or CT guidance. 10 The prognosis is good if diagnosis is made early and treatment is commenced timeously. Conclusion Although tuberculous liver abscess is very rare, it should be considered in the differential diagnosis of mass or cystic lesions of the liver especially in a high TB prevalence country. References 1. Chen TC, Chou LT, Huang CC, Lai AB, Wang JH. Iso- lated tuberculous liver abscess in an immunocompe- tent adult patient: A case report and literature review. Journal of Microbiology, Immunology and Infection. 2016 June; 49(3): p. 455-458. 2. Kielhofner A, Hamill RJ. Focal Hepatic Tuberculosis in a patient with Acquired Immunodeficiency Syndrome. South African Medical Journal. 1991 March; 84(3): p. 401-404. Tuberculous liver abscess Dr. Y Qubekile, C. Gounden, Dr. VG Naidoo Department of Gastroenterology, Nelson Mandela School of Medicine, University of Kwa-Zulu Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa Correspondence Y Qubekile email: yqubekile@yahoo.com CASE REPORT Introduction Tube culosis (TB) is common i tuberculous iver bscess (TLA entity with prevalence of 0.35 hepatic TB. 1 Less than 25 cases the literature prior to 2003. Foc be nifested by single or mul abscesses. 2 These occur more immunocompromised patients with foci of infection in the lung tract. 3 We descr be a case of fo type 2 diabetes mellitus (DM). Case presentation A 57-year-old male known with hypertension presented with 2- rogressive righ upper quadr vomiting, fev , chills and rigor of approximately 20kg. On exa but no ja ndice or lymphadeno xam nation revealed point ten There was no splenomegaly, a Respiratory exam revealed a ri Investi ations revealed a wh 109/L, erythrocyte segmentatio functio tests were normal exc phosphatase 419 U/L and gam 207 U/L. Human immunodeficie nd hydatid serology were neg ultrasou d showed a large cyst 8.2cm x 9.6cm) with ill-defined hypoechoic components in seg P s was aspir ted under ultras sent for cytology and microbiol Polymera e chain reaction testi culture were negative for TB w multiple acid-fast bacilli (AFB) staining. Pleurocentesis done s effusion with no acid-fast bacilli culture wer negative. A diagnosis of TLA was mad commenced on standard inten anti-tuberculous treatment. Per the liver abscess was done. Re confirmed resolution of clinical gained weight with no RUQ ten ultrasound showed resolution o evidence of r collection. Ther pleural effusion. He completed treatment. Tubercul Dr. Y Qubekile, C. Gounden, Dr. Department of Gastroenterology, N Hospital, Durban, South Africa Correspondence Y Qubekile email: yqubekile@yahoo.com