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.