Clinical Radiology (1991) 43, 215-216
Case Report: Tuberculous Hepatic and Splenic Abscess C. C. W I L D E
a n d Y. K. K U E H *
Departments of Radiology and *Internal Medicine, National University of Singapore, National University Hospital, Singapore Tuberculous abscess of the liver is rare and delay in diagnosis is common. The case of a 66-yearold Singaporean Chinese female with tuberculous liver abscess is reported. The abscess had an unusual septated ('honeycomb-like') ultrasonographic and computed tomographic appearance and the diagnosis was made with difficulty from material aspirated from the hepatic lesion. W i l d e , C . C . & K u e h , Y . K . (1991). Clinical Radiology 43, 2 1 5 - 2 1 6 . C a s e R e p o r t : Tuberculous Hepatic and Splenic Abscess
T u b e r c u l o s i s is n o t a c o m m o n c a u s e o f liver abscess a n d is only r a r e l y c o n s i d e r e d in t h e differential d i a g n o s i s o f a p a t i e n t w i t h a h e p a t i c mass. O u r r e v i e w o f t h e i n d e x e d literature since 1930 i n c l u d e d a t o t a l o f 444 r e p o r t e d cases o f t u b e r c u l o s i s o f the liver. P a t i e n t s u s u a l l y p r e s e n t e d with p y r e x i a o f u n d e t e r m i n e d origin, a n o r e x i a , w e i g h t loss, a b d o m i n a l p a i n a n d the d i a g n o s i s was m a d e at e x p l o r a t o r y l a p a r o t o m y o r a u t o p s y ( H e r s c h , 1964a, b; G r a c e y , 1965; G u l a t i a n d Vyas, 1965; P i n e d a a n d D a l m a c i o - C r u z , 1965; Z i p s e r et al., 1976; A l v a r e z a n d C a r p i o , 1983). W e r e c e n t l y e n c o u n t e r e d a case o f t u b e r c u l o u s liver and splenic abscesses. It d e m o n s t r a t e s t h a t a m o r e aggressive s e a r c h f o r l a b o r a t o r y e v i d e n c e o f t u b e r c u l o s i s can l e a d to e a r l y a p p r o p r i a t e t h e r a p y in this o t h e r w i s e fatal disease.
CASE REPORT A 66-year-old Chinese woman was admitted to hospital in April 1988 with a history of anorexia and weight loss. She had been in good health until 6 months previously. Physical examination revealed low grade fever and tenderness in the right upper abdomen. A chest radiograph was normal. Laboratory studies revealed a normochromic, normocytic anaemia and a white blood cell count of 15 x 109/1with a monocytosis of 7%. Liver functional tests were within normal limits with the exception of an elevated alkaline phosphatase of 187 u/1 (normal 20 95). A bone marrow aspirate was not diagnostic. Ultrasound (US) and computerized tomography (CT) of the abdomen demonstrated multiple 'honey-
Fig. 2 CT shows similar appearances to Fig. 1. A separated abscess is also visualized within the spleen.
combed-like' hepatic and splenic masses (Figs 1 and 2). A C T guided needle biopsy of the mass in the right hepatic lobe yielded a small amount of greyish thick material. Gram and acid fast stains were not diagnostic. Cytologic and histological examination revealed only amorphous necrotic material. Routine aerobic and anaerobic cultures resulted in no growth and a sample was sent for fungal and mycobacteriaI cultures. The patient was treated with cefotaxime, amikacin and metronidazol for suspected polymicrobial abscess. One month later, she deteriorated further, became obtunded and comatose. Neurological examination revealed no localizing signs, CT of the head was normal and examination of spinal fluid was unremarkable. Repeat ultrasound of the liver revealed further enlargement of the multiple hepatic and splenic abscesses. An ultrasound guided percutaneous drainage of the liver abscess yielded 10 15 ml of blood tinged thick fluid. Acid fast and Gram stains of this material again revealed no organisms but a report from the previous mycobacterial culture had now become available. It was positive for Mycobacterium tuberculosis (var. hominis). Culture of material aspirated during the second admission also grew M. tuberculosis'.The patient was started on isoniazid, rifampicin and ethambutol and her clinical condition gradually improved. When last seen on 12 April 1989 (1 year later) she appeared to have regained her normal health and a repeat CT revealed disappearance of liver and splenic abscesses.
DISCUSSION Fig. 1 - Ultrasound showing the separated abscess in the caudate lobe of the liver in oblique and transverse planes. Correspondence to: Dr C. C. Wilde, Department of Diagnostic Radiology, National University Hospital, Lower Kent Ridge Road, Singapore 0511.
P r e v i o u s r e v i e w p a p e r s a n d case r e p o r t s d e s c r i b e the d e c e i v i n g clinical p r e s e n t a t i o n s o f t u b e r c u l o u s liver abscess ( M o r r i s , 1930; H e r s c h , 1964a, b; Z i p s e r et al., 1976; A l v a r e z a n d C a r p i o , 1983). P a t i e n t s m a y be afebrile a n d c h e s t r a d i o g r a p h s m a y be n o r m a l or r e v e a l o n l y m i n i m a l
216
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pleural effusion. T h e u s u a l initial clinical i m p r e s s i o n is one o f p y o g e n i c liver abscess, cancer o r amoebiasis. T h e multiple s e p t a t e d ( ' h o n e y c o m b e d - l i k e ' ) US a n d C T a p p e a r a n c e o f the abscesses in liver a n d spleen o f o u r p a t i e n t (Figs 1 a n d 2) is very u n u s u a l in o u r experience and led us to suspect an obscure aetiology. W e were u n a b l e to find any reference to this a p p e a r a n c e in previous reports. A c i d fast stains o f a s p i r a t e d or surgically r e m o v e d m a t e r i a l f r o m the abscess c a n be unrem a r k a b l e , a n d the results o f tuberculosis cultures d o n o t b e c o m e available for several weeks. Thus simple aspir a t i o n o f an abscess cavity is u s u a l l y n o t a d e q u a t e for diagnosis. H i s t o l o g i c a l samples are n o t helpful when only necrotic tissue is o b t a i n e d a n d an a t t e m p t should be m a d e to o b t a i n tissue f r o m the m a r g i n s o f an abscess. A diagnostic clue is p r o v i d e d b y a s t r o n g l y positive tuberculin skin test (Gracey, 1965; Z i p s e r et al., 1976) p a r t i c u l a r l y in countries with a low incidence o f tuberculosis.
Acknowledgements:We thank Mr Bernard Wee for the photographic work, and Ms Claire Lim and Jessie Lim for the preparation of this manuscript.
REFERENCES
Alvarez, SZ & Carpio, R (1983). Hepatobiliary tuberculosis. Digestive Diseases and Sciences, 28, 193-200. Gracey, L. (1965). Tuberculous abscess of the liver. British Journal of Surgery, 52, 442-443. Gulati, PD & Vyas, PB (1965). Tuberculosis of the liver. Journal of the Indian Medical Association, 45, 144-145. Hersch, C. (1964a). Tuberculosis of the liver. A study of 200 cases. South African Medical Journal, 38, 857-863. Hersch, C (1964b). Diagnostic problems in hepatic tuberculosis. Sud Afrikan Tydskrif vir Geneeskunde, 11, 906 910. Morris, E. (1930). Tuberculosis of the liver. American Review of Tuberculosis, 22, 585-592. Pineda, FM & Dalmacio-Cruz, A. (I 965). Tuberculosis of the liver and porta hepatis. Report of nine cases. Acta Medica Philippina, 2, 128 139. Zipser RD, Rau JE, Ricketts, RR & Bevans, LC (1976). Tuberculous pseudotumors of the liver American Journal of Medicine, 61, 946951.
Case Report: Tuberculous Hepatic and Splenic Abscess C. C. W I L D E
a n d Y. K. K U E H *
Departments of Radiology and *Internal Medicine, National University of Singapore, National University Hospital, Singapore Tuberculous abscess of the liver is rare and delay in diagnosis is common. The case of a 66-yearold Singaporean Chinese female with tuberculous liver abscess is reported. The abscess had an unusual septated ('honeycomb-like') ultrasonographic and computed tomographic appearance and the diagnosis was made with difficulty from material aspirated from the hepatic lesion. W i l d e , C . C . & K u e h , Y . K . (1991). Clinical Radiology 43, 2 1 5 - 2 1 6 . C a s e R e p o r t : Tuberculous Hepatic and Splenic Abscess
T u b e r c u l o s i s is n o t a c o m m o n c a u s e o f liver abscess a n d is only r a r e l y c o n s i d e r e d in t h e differential d i a g n o s i s o f a p a t i e n t w i t h a h e p a t i c mass. O u r r e v i e w o f t h e i n d e x e d literature since 1930 i n c l u d e d a t o t a l o f 444 r e p o r t e d cases o f t u b e r c u l o s i s o f the liver. P a t i e n t s u s u a l l y p r e s e n t e d with p y r e x i a o f u n d e t e r m i n e d origin, a n o r e x i a , w e i g h t loss, a b d o m i n a l p a i n a n d the d i a g n o s i s was m a d e at e x p l o r a t o r y l a p a r o t o m y o r a u t o p s y ( H e r s c h , 1964a, b; G r a c e y , 1965; G u l a t i a n d Vyas, 1965; P i n e d a a n d D a l m a c i o - C r u z , 1965; Z i p s e r et al., 1976; A l v a r e z a n d C a r p i o , 1983). W e r e c e n t l y e n c o u n t e r e d a case o f t u b e r c u l o u s liver and splenic abscesses. It d e m o n s t r a t e s t h a t a m o r e aggressive s e a r c h f o r l a b o r a t o r y e v i d e n c e o f t u b e r c u l o s i s can l e a d to e a r l y a p p r o p r i a t e t h e r a p y in this o t h e r w i s e fatal disease.
CASE REPORT A 66-year-old Chinese woman was admitted to hospital in April 1988 with a history of anorexia and weight loss. She had been in good health until 6 months previously. Physical examination revealed low grade fever and tenderness in the right upper abdomen. A chest radiograph was normal. Laboratory studies revealed a normochromic, normocytic anaemia and a white blood cell count of 15 x 109/1with a monocytosis of 7%. Liver functional tests were within normal limits with the exception of an elevated alkaline phosphatase of 187 u/1 (normal 20 95). A bone marrow aspirate was not diagnostic. Ultrasound (US) and computerized tomography (CT) of the abdomen demonstrated multiple 'honey-
Fig. 2 CT shows similar appearances to Fig. 1. A separated abscess is also visualized within the spleen.
combed-like' hepatic and splenic masses (Figs 1 and 2). A C T guided needle biopsy of the mass in the right hepatic lobe yielded a small amount of greyish thick material. Gram and acid fast stains were not diagnostic. Cytologic and histological examination revealed only amorphous necrotic material. Routine aerobic and anaerobic cultures resulted in no growth and a sample was sent for fungal and mycobacteriaI cultures. The patient was treated with cefotaxime, amikacin and metronidazol for suspected polymicrobial abscess. One month later, she deteriorated further, became obtunded and comatose. Neurological examination revealed no localizing signs, CT of the head was normal and examination of spinal fluid was unremarkable. Repeat ultrasound of the liver revealed further enlargement of the multiple hepatic and splenic abscesses. An ultrasound guided percutaneous drainage of the liver abscess yielded 10 15 ml of blood tinged thick fluid. Acid fast and Gram stains of this material again revealed no organisms but a report from the previous mycobacterial culture had now become available. It was positive for Mycobacterium tuberculosis (var. hominis). Culture of material aspirated during the second admission also grew M. tuberculosis'.The patient was started on isoniazid, rifampicin and ethambutol and her clinical condition gradually improved. When last seen on 12 April 1989 (1 year later) she appeared to have regained her normal health and a repeat CT revealed disappearance of liver and splenic abscesses.
DISCUSSION Fig. 1 - Ultrasound showing the separated abscess in the caudate lobe of the liver in oblique and transverse planes. Correspondence to: Dr C. C. Wilde, Department of Diagnostic Radiology, National University Hospital, Lower Kent Ridge Road, Singapore 0511.
P r e v i o u s r e v i e w p a p e r s a n d case r e p o r t s d e s c r i b e the d e c e i v i n g clinical p r e s e n t a t i o n s o f t u b e r c u l o u s liver abscess ( M o r r i s , 1930; H e r s c h , 1964a, b; Z i p s e r et al., 1976; A l v a r e z a n d C a r p i o , 1983). P a t i e n t s m a y be afebrile a n d c h e s t r a d i o g r a p h s m a y be n o r m a l or r e v e a l o n l y m i n i m a l
216
CLINICAL RADIOLOGY
pleural effusion. T h e u s u a l initial clinical i m p r e s s i o n is one o f p y o g e n i c liver abscess, cancer o r amoebiasis. T h e multiple s e p t a t e d ( ' h o n e y c o m b e d - l i k e ' ) US a n d C T a p p e a r a n c e o f the abscesses in liver a n d spleen o f o u r p a t i e n t (Figs 1 a n d 2) is very u n u s u a l in o u r experience and led us to suspect an obscure aetiology. W e were u n a b l e to find any reference to this a p p e a r a n c e in previous reports. A c i d fast stains o f a s p i r a t e d or surgically r e m o v e d m a t e r i a l f r o m the abscess c a n be unrem a r k a b l e , a n d the results o f tuberculosis cultures d o n o t b e c o m e available for several weeks. Thus simple aspir a t i o n o f an abscess cavity is u s u a l l y n o t a d e q u a t e for diagnosis. H i s t o l o g i c a l samples are n o t helpful when only necrotic tissue is o b t a i n e d a n d an a t t e m p t should be m a d e to o b t a i n tissue f r o m the m a r g i n s o f an abscess. A diagnostic clue is p r o v i d e d b y a s t r o n g l y positive tuberculin skin test (Gracey, 1965; Z i p s e r et al., 1976) p a r t i c u l a r l y in countries with a low incidence o f tuberculosis.
Acknowledgements:We thank Mr Bernard Wee for the photographic work, and Ms Claire Lim and Jessie Lim for the preparation of this manuscript.
REFERENCES
Alvarez, SZ & Carpio, R (1983). Hepatobiliary tuberculosis. Digestive Diseases and Sciences, 28, 193-200. Gracey, L. (1965). Tuberculous abscess of the liver. British Journal of Surgery, 52, 442-443. Gulati, PD & Vyas, PB (1965). Tuberculosis of the liver. Journal of the Indian Medical Association, 45, 144-145. Hersch, C. (1964a). Tuberculosis of the liver. A study of 200 cases. South African Medical Journal, 38, 857-863. Hersch, C (1964b). Diagnostic problems in hepatic tuberculosis. Sud Afrikan Tydskrif vir Geneeskunde, 11, 906 910. Morris, E. (1930). Tuberculosis of the liver. American Review of Tuberculosis, 22, 585-592. Pineda, FM & Dalmacio-Cruz, A. (I 965). Tuberculosis of the liver and porta hepatis. Report of nine cases. Acta Medica Philippina, 2, 128 139. Zipser RD, Rau JE, Ricketts, RR & Bevans, LC (1976). Tuberculous pseudotumors of the liver American Journal of Medicine, 61, 946951.
