Tuberculosis of the liver is a rare form of extra pulmonary tuber-culosis, and is seen more commonly in immunocompromised patients or in association with disseminated tuberculosis. Liver involvement without involvement of lung or other organs is rare. Nodular form of liver tuberculosis presenting as abscess is uncommon, and is commonly mistaken for pyogenic/amebic liver abscess or malignancy. Definitive diagnosis requires detection of tubercular bacillus in pus or liver biopsy [1].

A 12-year-old girl presented with non-localized upper abdominal pain for 3 months, with history of fever off-and-on and weight loss of 4 kg in two months. There was no history of previous hospitalization or contact with tuberculosis. Immuni-zation was complete as per national immunization schedule; however, BCG scar was absent. On examination, child was stunted and wasted (weight for age at –2.04 z-score, height for age at –2.54 z-score as per IAP charts). General physical examination revealed severe pallor, angular cheilitis, mucositis and knuckle hyperpigmentation, with no lymphadenopathy. On systemic examination, there was hepatomegaly with other systems being unremarkable. Chest radiograph was normal. Ultrasonography abdomen revealed a large heterogenous solid cystic mass lesion involving the segment VIII and IV of liver, extending till the subcapsular regions. A possibility of hydatid cysts,　multiple pyogenic abscesses and fungal abscesses was kept. On laboratory evaluation, hemogram was performed: Hemoglobin 4.4 gm/dL, total leucocyte count 17200/mm3 (lymphocytes 18%, neutrophils 78%) and peripheral smear revealed dimorphic blood picture with microcytic hypochromic and macrocytic normochromic red cells. ESR was raised (60 mm/h); liver and renal function tests were normal. Serum iron levels (40 mcg/dL) and serum B12 levels (160 pg/mL) were both low. Mantoux　test and gastric aspirate for cartridge based nucleic acid amplification test (CBNAAT) were negative. Stool microscopy did not reveal cyst or ova and HIV test and immunodeficiency work up was negative. Computed tomo-graphy (CT) scan of abdomen revealed a large ill-defined heterogeneously hypodense mass lesion involving the left and right lobes (segment VIII and IV) of liver, faintly hyperdense internal septations could be seen (Fig. 1). A possibility of hydatid cysts and malignancy was kept. Hydatid serology was negative. CT-guided tru-cut needle biopsy was planned, for which the child was referred to a higher centre. Liver biopsy showed multiple epithelioid cell granulomas, positive for acid-fast bacilli on Ziehl Neelson (ZN) stain. A diagnosis of tuberculosis was made and child was started on directly observed treatment, short-course (DOTS) therapy for tuberculosis. On follow up after 2 months, child started gaining weight and repeat ultrasonography showed decreasing size of liver abscesses.　

Fig. 1 (a) Axial plain CT images reveal a large ill-defined heterogeneously hypodense mass lesion involving left and right lobes (segment VIII and IV) of liver; (b) Cystic appearing areas (black arrow) as well as solid slightly hyperdense areas (white arrow) seen within the lesion. Contrast enhanced CT scan shows axial images: late arterial phase (c) and porto venous phase (d), composed of solid and cystic areas. Cystic areas (black arrow) show no significant enhancement whereas solid areas show mild progressive enhancement (white arrow); Contrast enhanced CT scan shows coronal images of the lesion. (e) late arterial phase, (f) porto venous phase. Lesion is composed of solid and cystic areas. The cystic areas (black arrow) show no significant enhancement whereas solid areas show mild progressive enhancement (white arrow).

Primary hepatic tuberculosis without pulmonary or miliary tuberculosis is an uncommon diagnosis. The diagnosis is frequently missed due to lack of suspicion and can mimic other etiologies like bacterial, amebic or fungal liver abscess [2]. In a study from South Africa, in 296 patients with hepatic tuberculosis, tubercular abscess accounted for only 0.54% cases [3]. In an Indian study of 242 immunocompetent tuberculosis patients, 38 had liver involvement, of which 10 had tubercular liver abscess [4]. Patients usually present with fever, abdominal pain, anorexia, hepatomegaly and loss of weight with jaundice being an uncommon presentation. Right lobe of liver has been found to be more commonly involved (82.5%) [1].

Radiological findings are variable and insufficient for diagnosis. Majority of the cases have shown heterogenous, anechoic or hypoechoic lesions with irregular margins; however, some reports have described a hyperechoic mass [5]. Amebic or pyogenic liver abscess or hepatocellular carcinoma are the differential diagnosis. Definitive diagnosis can be made by detection of tubercular bacilli in pus or liver biopsy stained by ZN stain [1]. Although culture is the gold standard, but it requires long incubation period. Polymerase chain reaction has a sensitivity of 92.4% and specificity of 98%, and should be performed for rapid diagnosis [6].

We report this case to highlight a rare manifestation of a common disease. A high index of suspicion may help in timely diagnosis and avoid unnecessary investigations or surgical intervention.

1. Baveja C, Gumma V, Chaudhary M, et al. Primary tubercular liver abscess in an immunocompetent adult: A case report. J Med Case Rep. 2009;3:78.

2. Bhatt GC, Nandan D, Singh S. Isolated tuberculous liver abscess in immunocompetent children – Report of two cases. Pathog Glob Health. 2013;107: 35-37.

3. Essop AR, Moosa MR, Segal I, et al. Primary tuberculosis of the liver- A case report. Tubercle. 1983;64:291-3.

4. Amarapurkar DN, Patel ND, Amarapurkar AD. Hepatobiliary tuberculosis in western India. Indian J Pathol Microbiol. 2008; 51:175-81.

5. Chen HC, Chao YC, Shyu RY, et al. Isolated tuberculous liver abscesses with multiple hyperechoic masses on ultrasound: A case report and review of the literature. Liver Int. 2003;23:346-50.