Discussion:
TB infection remains one of the leading causes of death, especially in
developing countries.3 It is extremely important for
clinicians to understand the nature of the disease and its wide variety
of presentations, in addition to having a high index of suspension when
dealing with patients in areas where TB remains an endemic infection.
In extra-pulmonary TB, liver tuberculosis has been described as a rare
entity, but not an exceptional one. Isolated TLA is an extremely rare
condition, The incidence of which was found to be
0.34%.6 It is often misdiagnosed as a pyogenic or
amoebic abscess.4 Most of the cases in the literature
occur alongside miliary TB of the lungs, which spread to the liver by
hematogenous spread.5
The diagnosis of TLA has always been challenging as the symptoms of this
condition are not specific.7 Patients usually present
with constitutional symptoms like fever, anorexia, and weight loss. As
there are no specific symptoms, signs, or lab investigations for TLA,
diagnosis depends on a high index of suspicion, especially in patients
coming from endemic areas for TB. Radiological imaging modalities are
usually not helpful in differentiating between pyogenic, amoebic, or TB
liver abscess.8 In our case, our patient came with
vague symptoms, which manifested mainly as fever and abdominal pain.
The diagnosis of TLA requires the use of ZN stains, acid-fast bacilli
culture and PCR on the specimen collected.9 In liver
biopsies, granuloma formation can be seen in around 80% to 100% of
cases; and caseation in up to 83%.10 PCR assays are
positive in up to 88% of TLA cases.11 No specific lab
investigations can help diagnose TLA, with previous studies showing
elevated Alkaline phosphatase as the most frequent
finding.12
Medical treatment for TB is a debatable subject, with most centers
recommending treatment with Quadruple therapy for 1
year.13 In our case, treatment with Anti- TB
medication was started for the patient and he started showing
improvement within 1 week of starting the medications, and he was seen 1
month after discharge with complete resolution of the fever and his
previous symptoms.