Isolated tuberculous liver abscesses with multiple hyperechoic masses on ultrasound: a case report and review of the literature

Miliary Tuberculosis Initially Presenting as an Isolated Hepatic Abscess

Hepatic tuberculosis, typically associated with miliary tuberculosis, can occasionally present as localized liver lesions. This case report describes a 77-year-old male presenting with persistent abdominal pain and fever, following an endoscopic retrograde cholangiopancreatography for bile duct sludge removal. Subsequent computed tomography revealed focal liver lesions. Despite initial treatment with antibiotics for a suspected inflammatory liver abscess, his condition did not improve. A liver biopsy was performed, revealing caseous granulomas, and the tuberculosis polymerase chain reaction result was positive. The patient was diagnosed with primary hepatic tuberculosis, which later disseminated. Oral anti-tuberculosis therapy was initiated and is currently being closely monitored. This case emphasizes the importance of considering hepatic tuberculosis in the differential diagnosis of liver lesions, particularly in cases involving cholestatic liver function tests, and persistent symptoms unresponsive to conventional antibiotics.

Extra Pulmonary Tuberculosis Manifesting as Liver Abscess

Liver abscess is a rare presentation of extrapulmonary tuberculosis. It may present with nonspecific symptoms such as fever, weight loss and abdominal pain and requires a high degree of suspicion. We present a case of a 57-year-old male previously treated for a liver abscess and presented with abdominal pain, vomiting and fever and a contrast-enhanced computed tomography (CECT) showed a loculated liver abscess. Ultrasound-guided aspiration of the pus was sent for GeneXpert MTB (Cepheid, Sunnyvale, CA, USA) and mycobacterial culture which confirmed the diagnosis. The patient was started on anti-tubercular therapy and clinically improved.

Comments and Illustrations of Ultrasound Findings in Extrapulmonary Tuberculosis Manifestations

This review describes the appearance of extrapulmonary tuberculosis manifestations in comprehensive and multiparametric ultrasound imaging. The aim is to increase awareness of typical ultrasound findings regarding extrapulmonary tuberculosis, correlate those with pathological features, and facilitate differential diagnosis. Point of care ultrasound protocols can be used as a screening method in high-risk populations, although the negative findings do not exclude tuberculosis. Conversely, the diagnosis of extrapulmonary tuberculosis can never be made using ultrasound alone, as many ultrasound findings in extrapulmonary tuberculosis are non-specific. However, ultrasound-based sampling techniques can significantly facilitate the collection of samples for microbiological or molecular proof of tuberculosis, as well as facilitating the establishment of alternative diagnoses.

Hepatobiliary tuberculosis in the developing world

BACKGROUND

Hepatobiliary tuberculosis is a challenging disease that poses diagnostic difficulties due to its resemblance to other etiologies. Delayed diagnosis may lead to inadequate treatment, thus necessitating an urgent need for accurate diagnosis and appropriate management.

AIM

To systematically review case reports on hepatobiliary tuberculosis, focusing on symptomatology, diagnostic procedures, management, and outcomes to provide patient safety and ensure an uneventful recovery.

METHODS

A systematic search was conducted on PubMed from 1992 to 2022, using keywords such as hepatobiliary, liver, tuberculosis cholangitis, cholangiopathy, and mycobacterium. Only case reports or case series in English were included in the study, and research papers published as abstracts were excluded. The search yielded a total of 132 cases, which were further narrowed down to 17 case studies, consisting of 24 cases of hepatobiliary tuberculosis.

RESULTS

The 10 most common symptoms observed in these cases were fever, abdominal pain, weight loss, jaundice, anorexia, generalized weakness, pruritus, chills, fatigue, and chest pains. Objective findings in these cases included hepatomegaly, hepatic nodules, elevated liver enzymes, and elevated bilirubin. Computed tomography scan and ultrasound of the abdomen were the most useful diagnostic tools reported. Histologic demonstration of Mycobacterium tuberculosis confirmed the cases of hepatobiliary tuberculosis. Treatment regimens commonly used included Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol. Out of the 24 cases, 18 presented improvements while 4 had completely recovered.

CONCLUSION

Hepatobiliary tuberculosis is a disease that requires accurate diagnosis and appropriate management to avoid complications.

Tuberculous liver abscess as a unique cause of liver abscess: A case report and literature review

Introduction

TLA is most commonly associated with an immunocompromised state, a focus of infection in the lungs or gastrointestinal system, or as part of congenital or miliary tuberculosis. Isolated TLA is rare, with only a few cases reported in the literature.

Methods

We describe a case of a 24-years-old healthy male with an isolated Tuberculous Liver abscess presented with prolonged fever, abdominal pain, and general malaise. He was successfully treated with a 6-month antituberculosis regimen and percutaneous abscess drainage.

Discussion and conclusion

The signs and symptoms of isolated TLA are nonspecific. The diagnosis requires a high index of suspicion, especially in endemic areas and in individuals with a known tuberculosis risk factor. A better outcome is linked to an early diagnosis and timely treatment with systemic Antituberculous medications. This case report highlights the importance of considering TLA (Tuberculous or Tubercular Liver Abscess) when diagnosing hepatic masses or abscesses as a possible cause of extrapulmonary tuberculosis (EPTB).

Tubercular Hepatic Abscess: An Incidental Finding

Tuberculosis (TB) is an infectious disease caused by a bacterium, Mycobacterium tuberculosis. It is known to generally affects the lungs, but it can also affect multiple other parts of the body. Liver involvement with hepatic abscess is an infrequent manifestation of TB which is missed because of the rarity and non-specific symptoms, especially in the west. A thorough literature review shows very few case reports published in the western world. We present a rare case of isoniazid-resistant pulmonary TB associated with a hepatic abscess in the United States. It was diagnosed by aspiration of the abscess that later grew M. tuberculosis and treated with antitubercular drugs.

Isolated hepatic tuberculosis associated with portal vein thrombosis and hepatitis B virus coinfection: A case report and review of the literature

BACKGROUND

While tuberculosis (TB) itself is a common disease, isolated TB of the liver is a rare entity. Tubercular involvement of the liver is more commonly a part of a disseminated disease of the hepatic parenchyma. In contrast, isolated hepatic TB spread through the portal vein from the gastrointestinal tract is seldom encountered in clinical practice, with only a few sporadic cases and short series available in the current literature. Vascular complications, such as portal vein thrombosis (PVT), have rarely been reported previously.

CASE SUMMARY

A 22-year-old man was hospitalized with complaints of a 3-mo history of fever and weight loss of approximately 10 kg. He had a 10-year hepatitis B virus (HBV) infection in his medical history. Contrast-enhanced computed tomography (CECT) confirmed hepatosplenomegaly, with hypodensity of the right lobe of the liver and 2.1 cm thrombosis of the right branch of the portal vein. A liver biopsy showed epithelioid granulomas with a background of caseating necrosis. Ziehl-Nelson staining showed acid-fast bacilli within the granulomas. The patient was diagnosed with isolated hepatic TB with PVT. Anti-TB therapy (ATT), including isoniazid, rifapentine, ethambutol, and pyrazinamide, was administered. Along with ATT, the patient was treated with entecavir as an antiviral medication against HBV and dabigatran as an anticoagulant. He remained asymptomatic, and follow-up sonography of the abdomen at 4 mo showed complete resolution of the PVT.

CONCLUSION

Upon diagnosis of hepatic TB associated with PVT and HBV coinfection, ATT and anticoagulants should be initiated to prevent subsequent portal hypertension. Antiviral therapy against HBV should also be administered to prevent severe hepatic injury.

Contrast-Enhanced Ultrasound LI-RADS LR-5 in Hepatic Tuberculosis: Case Report and Literature Review of Imaging Features

Background: The liver is involved in disseminated tuberculosis in more than 80% of cases while primary liver involvement is rare, representing <1% of all cases. Hepatic tuberculosis (TB) can be treated by conventional anti-TB therapy; however, diagnosing this disease remains a challenge. The diagnosis might be particularly difficult in patients with a single liver lesion that could be misdiagnosed as a tumor or other focal liver lesions. Although computed tomography (CT) and magnetic resonance imaging (MRI) findings have been described, there is a paucity of literature on contrast-enhanced ultrasound (CEUS) features of hepatic TB. Case Summary: herein, we describe a case of a patient with tuberculous lymphadenopathy and chronic Hepatitis C Virus (HCV)-related liver disease who developed a single macronodular hepatic TB lesion. Due to the finding of a hepatocellular carcinoma (HCC) highly suggestive CEUS pattern, specifically a LR5 category according to the Liver Imaging Reporting and Data System (LI-RADS), and a good response to antitubercular therapy, a non-invasive diagnosis of HCC was made, and the patient underwent liver resection. We also review the published literature on imaging features of hepatic TB and discuss the diagnostic challenge represented by hepatic TB when occurs as a single focal liver lesion. Conclusions: this report shows for the first time that the CEUS pattern of hepatic TB might be misinterpreted as HCC and specific imaging features are lacking. Personal history and epidemiological data are mandatory in interpreting CEUS findings of a focal liver lesion even when the imaging pattern is highly suggestive of HCC.

Primary isolated hepatic tuberculosis mimicking small hepatocellular carcinoma: A case report

RATIONALE

Mycobacterium tuberculosis (TB) remains a serious threat in developing countries. Primary isolated hepatic tuberculosis is extremely rare. Because of its non-specific imaging features, noninvasive preoperative imaging diagnosis of isolated hepatic tuberculoma remains challenging.

PATIENT CONCERNS

A 48-year-old man was admitted to our hospital due for suspected liver neoplasm during health examination.

DIAGNOSES

The tests for blood, liver function, and tumor markers were within normal range. Preoperative ultrasonography (US) showed a hypoechoic lesion with a longitudinal diameter of 2.5 cm in segment six of liver. It exhibited early arterial phase hyperenhancement and late arterial phase rapid washout in contrast-enhanced US. It demonstrated hyperintensity in T2-weighted magnetic resonance imaging and partly restricted diffusion in diffusion-weighted imaging. For this nodule, the preoperative diagnosis was small hepatocellular carcinoma (HCC).

INTERVENTIONS

Laparoscopic hepatectomy was performed. Intraoperative extensive adhesion in the abdominal cavity and liver was found. The lesion had undergone expansive growth.

OUTCOMES

Microscopically, a granuloma with some necrosis was detected. With both acid-fast staining and TB fragment polymerase chain reaction showing positive results, TB was the final histology diagnosis. After surgery, the patient declined any anti-TB medication. During the follow-up, he had no symptoms. In the sixth month after surgery, he underwent an upper abdominal US. It showed no lesions in the liver.

LESSONS

Because of non-specific imaging findings and non-specific symptoms, a diagnosis of isolated hepatic TB is difficult to make, especially for small lesions. A diagnosis of HCC should be made cautiously when small isolated lesions in the liver are encountered, especially in patients without a history of hepatitis and with negative tumor markers.

Looking beyond appearances: when liver biopsy is the key for hepatic tuberculosis diagnosis

Primary hepatic tuberculosis is a rare clinical entity with non-specific clinical and imaging features that can mimic other liver diseases, representing a diagnostic challenge. We report a case of a 35-year-old man with metabolic syndrome, type 2 diabetes and high alcohol consumption presenting asymptomatic with abnormal liver tests, hepatosplenomegaly and diffuse hepatic steatosis in ultrasound imaging initially suspected to be alcoholic steatohepatitis but later diagnosed as hepatic tuberculosis in the histological specimen. Anti-tuberculosis therapy was started. This clinical case highlights the diagnostic difficulty of hepatic tuberculosis and the importance of not overlooking liver biopsy and to consider it in the differential diagnosis in patients with obvious hepatic injury factors but with atypical clinical presentation.

Primary hepatic tuberculosis masquerading as intrahepatic cholangiocarcinoma

Abdominal tuberculosis is a common clinical entity in Indian subcontinent; however, hepatic tuberculosis in the absence of miliary abdominal tuberculosis is restricted to the case reports and small case series in English literature. It mimics common liver diseases like liver abscess and tumours. We report a case of 38 years old male presenting with abdominal pain, loss of appetite and weight initially misdiagnosed as intrahepatic cholangiocarcinoma on magnetic resonance imaging and FNAC of the lesion but later diagnosed as a case of hepatic tuberculosis on post operative histopathology specimen. It is important to consider tuberculosis in the differential diagnosis when suspecting lymphoproliferative or metastatic diseases in a patient with vague symptoms.

Tuberculosis as an Etiological Factor in Liver Abscess in Adults

Background. Tuberculosis of the liver without active pulmonary or miliary tuberculosis is considered as an uncommon diagnosis. The aim of the present study was to determine the etiological role of tuberculosis in adult patients presenting with features of liver abscess. Methods. A total of 40 patients with liver abscess were included in the study. The liver abscess aspirate was subjected to microscopy, culture, and polymerase chain reaction to determine the role of tuberculosis as an etiological factor in liver abscess. Results. Of the 40 patients enrolled, 25% (10/40) were diagnosed with having tubercular liver abscess. In a total of 40 specimens, 2.5% (1/40) were positive for acid fast bacilli by Ziehl-Neelsen method, while 10% (4/40) were positive for M. tuberculosis by culture using BACTEC 460 and the yield increased to 25% (10/40) by polymerase chain reaction for M. tuberculosis. Conclusion. 25% of the patients presenting with liver abscess had tubercular etiology without features of active pulmonary or miliary tuberculosis. Liver can act as the primary site of involvement in the absence of activity elsewhere in the body. Tuberculosis should be considered as an important differential diagnosis of liver abscess irrespective of evidence of active tuberculosis elsewhere in the body.

Primary Tubercular Liver Abscess Complicated by Tubercular Meningitis in Portal Cavernoma Cholangiopathy

While hepatic tuberculosis is rare, primary tubercular liver abscess (TLA) is a rarer condition even in endemic countries such as India. Liver abscess in portal cavernoma cholangiopathy (PCC) is predominantly pyogenic. A 14-year-old girl was found to have PCC with multiple liver abscesses. Persistent fever and development of neurological symptoms prompted further evaluation, and she was found to have primary TLA complicated by tubercular meningitis. We report a rare case of primary TLA complicated by tubercular meningitis in asymptomatic PCC.

Hepatic tuberculosis: a multimodality imaging review

OBJECTIVES

We aim to illustrate the multimodal imaging spectrum of hepatic involvement in tuberculosis (TB). Whilst disseminated tuberculosis on imaging typically manifests as multiple small nodular lesions scattered in the liver parenchyma, isolated hepatic tuberculosis remains a rare and intriguing entity.

METHODS

Indubitably, imaging is the mainstay for detection of tubercular hepatic lesions which display a broad spectrum of imaging manifestations on different modalities. While sonography and computed tomography (CT) findings have been described in some detail, there is a paucity of literature on magnetic resonance imaging (MRI) features. Due to a significant overlap with other commoner and similar appearing hepatic lesions, hepatic tuberculosis is often either misdiagnosed or labelled as indeterminate lesions. This article is a compendium of cases highlighting the spectrum of imaging patterns that can be encountered in patients with isolated primary hepatic tuberculosis as well as disseminated (secondary) disease. Rare patterns of primary disease such as tubercular cholangitis, hypervascular liver masses, and those with vascular complications are also illustrated and discussed.

CONCLUSIONS

Imaging plays a valuable role in the detection of tubercular hepatic lesions. Also, imaging can be helpful in their characterisation and for assessing associated complications.

TEACHING POINTS

• Hepatic TB has myriad imaging manifestations and is often confounded with neoplastic lesions. • Imaging patterns include miliary TB, macronodular TB, serohepatic TB and tubercular cholangitis. • Concurrent splenic, nodal or pulmonary involvements are helpful pointers towards the diagnosis. • Miliary calcifications along the bile ducts are characteristic of tubercular cholangitis. • Histological/microbiological confirmation is often necessary to confirm the diagnosis.

Primary hepatic tuberculosis mimicking intrahepatic cholangiocarcinoma: report of two cases

Hepatic tuberculosis (TB) is usually associated with pulmonary or miliary TB, but primary hepatic TB is very uncommon even in countries with high prevalence of TB. The clinical manifestation of primary hepatic TB is atypical and imaging modalities are unhelpful for differential diagnosis of the liver mass. Image-guided needle biopsy is the best diagnostic method for primary hepatic TB. In the cases presented here, we did not perform liver biopsy because we believed the liver masses were cholangiocarcinoma, but primary hepatic TB was ultimately confirmed by postoperative pathology. Here we report two cases of patients who were diagnosed with primary hepatic TB mimicking mass-forming intrahepatic cholangiocarcinoma.

Primary hepatic tuberculosis presenting as acute liver failure

Abdominal tuberculosis is a common clinical entity in Indian subcontinent; however, hepatic tuberculosis in the absence of miliary abdominal tuberculosis is restricted to the case reports and small case series in English literature. It mimics common liver diseases like liver abscess and tumors. We report a case of 25-year-old immunocompetent female who presented with features of acute liver failure. Ultrasonography (USG) abdomen revealed multiple hypoechoic lesions. However, patient expired within 48 h of presentation but her liver autopsy revealed multiple epithelioid cell caseating granulomas with positive staining for acid fast bacilli (AFB). Polymerase chain reaction (PCR) was also positive for Mycobacterium tuberculosis.

Tubercular liver abscess: an uncommon presentation of disseminated tuberculosis

We present a case of tubercular liver abscess with disseminated tuberculosis, associated with underlying HIV infection. The patient responded well to percutaneous drainage of the abscess and first-line quadruple antitubercular therapy. We report this case to highlight a rare manifestation of a common disease and to create greater awareness which may ensure timely diagnosis and avoid unnecessary surgical intervention.

Isolated hepatic tuberculosis mimicking liver tumors in a dialysis patient

Cases of isolated hepatic tuberculosis (TB) are rare. The diagnosis is often delayed or missed because of nonspecific symptoms and laboratory findings. Besides, the disease is extremely rare even in a country where TB is an alarming public health problem. This report demonstrates the difficulty in correctly diagnosing local hepatic TB. We report the case of a 62-year-old male patient with end-stage renal disease treated with hemodialysis, who developed 2 months of abdominal distension and general anorexia, with hyperechoic hepatic lesions on ultrasound. Computed tomography suspected multiple liver tumors. The liver biopsy finally led to the diagnosis of TB of the liver without other involvements. We conclude that isolated hepatic TB is one of the rare forms of extrapulmonary TB in dialysis patients. A greater awareness of this rare clinical entity may prevent needless surgical interventions.

Isolated tuberculous liver abscess in an immunocompetent adult patient: A case report and literature review

Tuberculous liver abscess is a rare disease entity even in endemic areas of Mycobacterium tuberculosis. It is usually accompanied by pulmonary tuberculosis or enteric tuberculosis. Further, an isolated tuberculous liver abscess is extremely rare. The disease is diagnosed by laparotomy or postmortem autopsy in most cases, and some authors adopted a 9-month antituberculosis regimen. We herein report a case of an isolated tuberculous liver abscess that initially manifested as persistent fever and general malaise, which was diagnosed by liver biopsy and treated successfully with a 6-month antituberculosis regimen and percutaneous abscess drainage.

Mixed pyogenic and tuberculous liver abscess: clinical suspicion is what matters

Tuberculosis (TB) is a rare cause of liver abscess, even in country like India where it is a very common infection. Moreover, tubercular liver abscess (TLA) is the most unusual pattern of hepatic tuberculosis. We report an unusual case of liver abscess in an immune-competent patient presenting only with weight loss. On investigation, initially it appeared pyogenic, but later turn out to be a mixed infection with tuberculosis. He responded well to antibiotic and antitubercular drugs. A mixed pyogenic and TLA is very uncommon. We conclude that, tuberculosis should be suspected in liver abscess, especially in the absence of typical features and failure to respond to antibiotics.

Clinical characteristics and the usefulness of the QuantiFERON-TB Gold In-Tube test in hematologic patients with hepatic or splenic lesions

BACKGROUND/AIMS

Hepatic or splenic lesions in hematologic patients are not defined well because they are not easy to evaluate due to limitations of invasive procedures. Management typically depends on the clinical diagnosis with few microbiological data.

METHODS

We reviewed the medical records of consecutive hematologic patients with hepatic or splenic lesions in the infectious diseases unit from April 2009 to December 2010 at the Catholic Hematopoietic Stem Cell Transplantation Center in Korea.

RESULTS

Twenty-six patients were identified. Their mean age was 46.0 ± 14.7 years, and 16 (61.5%) were male. Underlying diseases were acute myelogenous leukemia (n = 15, 57.7%) and myelodysplastic syndrome (n = 6, 23.1%). Among the nine nontuberculous infectious lesions, two bacterial, six fungal, and one combined infection were identified. The numbers of confirmed, probable, and possible tuberculosis (TB) cases were one, three, and four, respectively. Two patients had concurrent pulmonary TB. QuantiFERON-TB Gold In-Tube (QFT-GIT, Cellestis Ltd.) was positive in seven cases, among which six were diagnosed with TB. The sensitivity and specificity of QFT-GIT were 75% and 81.3%. Nine (34.6%) were defined as noninfectious causes.

CONCLUSIONS

Causes of hepatic or splenic lesion in hematologic patients were diverse including TB, non-TB organisms, and noninfectious origins. TB should be considered for patients not responding to antibacterial or antifungal drugs, even in the absence of direct microbiological evidence. QFT-GIT may be useful for a differential diagnosis of hepatosplenic lesions in hematologic patients.

Isolated tuberculosis of the liver: a diagnostic challenge

A 46-year-old gentleman, being investigated for symptoms of generalised weakness, low-grade fever and weight loss, was found to have a large, infiltrative mass of the liver on CT scan. The radiological impression was that of advanced hepatic malignancy with involvement of lesser curve of the stomach and regional lymph nodes. Multiple biopsy attempts failed to yield an adequate tissue sample for histopathological diagnosis. Surgery was planned for left hemihepatectomy with resection of the hepatogastric ligament and partial gastrectomy. Frozen section of a peroperative tissue sample confirmed the diagnosis of hepatic tuberculosis (TB). The granulomatous area was debrided and anti-TB treatment was started postoperatively. Recovery was unremarkable and the patient is currently asymptomatic.

Infectious diseases and the liver

The liver plays an important role in host defense against invasive microorganisms. The effect of microbial pathogens on the liver can vary greatly, presenting with a wide variety of manifestations from asymptomatic increases in aminotransaminases, acute liver failure, hepatic fibrosis, and cirrhosis. In evaluating the liver manifestations of a potential infectious pathogen, diagnosis of some of the less common infectious pathogens is dependent on a high level of suspicion and recognition of some of the key diagnostic clues. Successful diagnosis can only be accomplished through a careful history, including travel and exposures, physical examination, and appropriate microbiologic studies. This article reviews the involvement of the liver during systemic infections with organisms that are not considered to be primarily hepatotropic.

The nodular form of hepatic tuberculosis: contrast-enhanced ultrasonographic findings with pathologic correlation

OBJECTIVE

The purposes of this study were to describe the ultrasonographic findings in hepatic tuberculosis (TB) after administration of a second-generation sulfur hexafluoride-filled microbubble contrast agent and to correlate these findings with pathologic characteristics.

METHODS

Twenty-four hepatic TB lesions in 15 patients were studied with conventional ultrasonography (CUS) and contrast-enhanced ultrasonography (CEUS). Pathologic characteristics of the lesions were evaluated and were then correlated with enhancement patterns.

RESULTS

The appearance of hepatic TB on CUS was variable and nonspecific with respect to the shape, echogenicity, and boundary of the lesions. The diameters of the lesions obtained from CEUS were statistically larger than those from CUS, with largest diameters +/- SD of 4.2 +/- 1.8 and 3.1 +/- 1.9 cm, respectively. During the arterial phase, 13 of 24 lesions (54.2%) showed a rapidly and markedly enhanced rim with a hypoenhanced or nonenhanced center; 9 of 24 lesions (37.5%) showed transient enhancement of the whole lesion with inconsistent intensities. During the portal phase, most lesions showed distinct wash-out of the contrast agent and maintained a hypoechoic appearance. Pathologic studies confirmed that the different appearances of hepatic TB on CEUS were related to the different pathologic stages of the lesions.

CONCLUSIONS

Findings of hepatic TB on CEUS may be helpful in differentiating the diagnosis from other hepatic focal lesions. Correlation with pathologic findings would enrich the understanding of CEUS findings in hepatic TB.

Tuberculous liver abscess in a case without lung involvement

Hepatic tuberculosis is an uncommon form of extrapulmonary tuberculosis, particularly when it presents in the form of liver abscess. Here, we report a 64-year-old man who was admitted to our hospital having experienced intermittent chills for 3 months. Aspiration of the liver abscess revealed neither bacteria nor acid-fast bacilli, but pus and granulation tissue were found. Antituberculous therapy was started empirically and cultures of the abscess confirmed the presence of Mycobacterium tuberculosis 3 weeks later. We suggest that tuberculous liver abscess should be considered in patients not showing typical features or who fail to respond to antibiotics.

[Clinical features of hepatic tuberculosis in biopsy-proven cases]

BACKGROUNDS/AIMS

Hepatic involvement is frequently observed in patients with miliary tuberculosis, but primary hepatic tuberculosis with no clinical extrahepatic manifestations of tuberculosis is uncommon. With the ever-increasing number of immunocompromised patients, it is expected that hepatic tuberculosis will occur more frequently. The aim of the present study was to establish the clinical manifestations and course of the disease.

METHODS

From January 1989 to September 2008, 12 patients were diagnosed with hepatic tuberculosis by liver biopsy at Seoul National University Hospital. We retrospectively evaluated their clinical, laboratory, and imaging findings by medical record review.

RESULTS

Four patients had primary hepatic tuberculosis, and eight patients had hepatic tuberculosis secondary to pulmonary or miliary tuberculosis. Three patients were immunocompromised, and six patients had no previous medical problem. An elevated serum level of alkaline phosphatase was the most frequently observed finding in laboratory tests. Imaging studies showed variable findings, including hepatosplenomegaly, multiple hepatic nodules, abscess formation, and even normal findings. Ten patients responded to antituberculosis drugs, and two cases with tuberculous liver abscess had persistent disease despite prolonged therapy.

CONCLUSIONS

In patients with a protracted illness, hepatosplenomegaly and/or abnormal liver function tests, hepatic tuberculosis should be suspected, even in healthy young patients or patients with normal imaging findings. Patients with tuberculous abscess formation tend to respond poorly to antituberculosis therapy, and surgery could be considered in these patients.

Primary tubercular liver abscess in an immunocompetent adult: a case report

INTRODUCTION

Isolated primary tubercular abscess is one of the rare forms of extrapulmonary tuberculosis. A greater awareness of this rare clinical entity may help in commencing specific evidence-based therapy quickly and preventing undue morbidity and mortality.

CASE PRESENTATION

A 30-year-old man, of Asian origin, developed a hepatic tubercular abscess which was not associated with any pulmonary or gastrointestinal tract foci of tuberculosis. An ultrasonogram of the abdomen showed an abscess in the right lobe of his liver which was initially diagnosed as an amoebic liver abscess. Subsequently, the pus from the lesion yielded Mycobacterium tuberculosis using the BACTEC TB 460 instrument and Mycobacterium tuberculosis deoxyribonucleic acid by polymerase chain reaction. The patient was started on systemic antitubercular therapy to which he responded favorably.

CONCLUSION

This report emphasizes the fact that, although a tuberculous liver abscess is a very rare entity, it should be included in the differential diagnosis of unknown hepatic mass lesions.

Real-time contrast-enhanced ultrasound imaging of infected focal liver lesions

OBJECTIVE

The purpose of this study was to investigate the features of infected focal liver lesions on contrast-enhanced ultrasound (CEUS) imaging.

METHODS

Thirty-two hepatic abscesses, 15 infected granulomas, and 6 inflammatory pseudotumors in 53 patients were evaluated with real-time CEUS before awareness of the definitive diagnosis. A 2.4-mL dose of a sulfur hexafluoride-filled microbubble contrast agent was administered by intravenous bolus injection.

RESULTS

The numbers of abscesses with hyperenhancement, isoenhancement, and hypoenhancement in the arterial phase were 26 (81.3%), 5 (15.6%), and 1 (3.1%), respectively. Thirty (93.8%) lesions were irregularly rim enhanced with nonenhanced areas; enhanced septa were shown in 22 (68.8%) lesions; and transient hyperenhancement of liver parenchyma around the lesion was shown in 20 (62.5%). In 31 abscesses with hyperenhancement or isoenhancement in the arterial phase, 25 (80.6%) showed contrast wash-out and changed in appearance to hypoenhancement in the late phase. As for infected granulomas and inflammatory pseudotumors, 16 (76.2%) lesions showed hyperenhancement or isoenhancement in the arterial phase, and all of them were hypoenhanced in the portal and late phases.

CONCLUSIONS

Most infected focal liver lesions showed more rapid contrast wash-out than the surrounding liver parenchyma, which is similar to malignant lesions. Abscesses typically showed features of rim enhancement, enhanced internal septa, nonenhanced central necrotic areas, and transient hyperenhanced liver parenchyma around the lesions. The CEUS appearance of infected granulomas and inflammatory pseudotumors was variable, and a biopsy was necessary for definitive diagnosis.

Mitogen-activated protein kinase (MAPK) signalling pathways in HepG2 cells infected with a virulent strain of Klebsiella pneumoniae

Klebsiella pneumoniae (KP), an enterobacterium, usually causes urinary tract infection or pneumonia; however, it has caused severe liver abscess in diabetic patients in recent years. How this emerging virulent KP strain causes liver abscess is not known. This study investigates signalling pathways in HepG2 cells infected by virulent KP. Cells were infected with bacteria for various durations and harvested to screen for signalling molecules by Western blotting. Our results showed that phosphorylated mitogen-activated protein kinase (MAPK) kinase (MEK) 1/2, p44/p42 MAPK and p90 ribosomal S6 kinase (p90RSK) were observed and this pathway was inhibited by MEK1/2 inhibitors U0126 and PD98059. Phosphorylation of MEK3/6, p38 kinase and ATF-2 was also observed and this pathway was inhibited by p38 kinase inhibitors SB203850 and SB202190. Toll-like receptor (TLR) 2 and 4 expressions were increased and maximized 2-4 h post infection. The JNK pathway, Elk, MAPKAPK-2 and HSP27 were not activated. These results suggest that KP infections induce signal transduction through TLR2 and TLR4 and activate two downstream MAP kinase pathways, MEK1/2-p44/p42 MAPK-p90RSK and MEK3/6-p38 kinase-ATF-2, but not the JNK pathway in HepG2 cells. The infected HepG2 eventually showed apoptosis and died.

Subphrenic abscess and recurring focal lesions due to tuberculosis in a patient with IgA deficiency

Subdiaphragmatic abscess has not yet been reported as a manifestation of tuberculosis. We report an IgA deficient patient with recurrent episodes of unusual extrapulmonary manifestations of tuberculosis including subdiaphragmatic abscesses and metacarpophalangeal osteomyelitis that was improved each time with antituberculosis drugs. There was not any resistance to the drugs used against mycobacterium despite repeated courses of antituberculosis regimens. In such recurrent cases, one should rule out any immunodeficiency states.