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Introduction
Tuberculosis remains an important public health problem
in Bangladesh. Isolated liver tuberculosis (ILT) is still
considered a rare condition and hepatic tuberculosis is
usually associated with an active pulmonary or miliary
tuberculosis 1,2. Liver involvement in tuberculosis is
usually clinically silent. Isolated hepatic tuberculoma (syn.
nodular hepatic tuberculosis, macronodular hepatic
tuberculosis) is the rarest form of local hepatic tuberculosis
3. Tuberculosis presenting as an isolated liver tumor,
without active pulmonary or miliary tuberculosis, or other
clinical evidence of tuberculosis, is distinctly rare 4. In
this report, we describe a rare case of isolated liver
tuberculosis without pulmonary spread.

Case Report
A 32-year-old male patient was admitted with right upper-
abdominal pain and feeling of abdominal distention for a
year. There was no history of exposure to tubeculosis. The
patient was well and the vital signs were stable. Physical
examination showed local epigastric tenderness without
hepatomegaly. Laboratory data revealed normal serum
hemoglobin level, a white blood cell count with slightly
increased eosinophils, normal erythrocyte sedimentation
rate, normal liver and renal function tests, and normal
coagulation tests. Tumor markers including alpha-
fetoprotein, CEA, CA 19-9 were normal.Viral marker s: HbsAg,
anti Hbc was also negative.FBS was high and pt was diabetic
getting insulin.There was no radiological finding of
tuberculosis in the Chest X-ray. Liver ultrasonography
showed a rounded Hypoechoic area measuring about 1.9cm
seen in  the right lobe and pancreatic calculi with mildly
dilated main pancreatic duct[MPD].ERCP was also done

A Case Report: Isolated Liver Tuberculosis
Zulfiqur Rhaman Khan1,  Md Mohsen Chowdhury2, Mohammad Saif Uddin3,  Md. Abu Taher4
1Professor, 2Associate Professor, 3Medical Officer, 4Assistant Professor, Department of Surgery, Bangabandhu Sheikh Mujib Medical University

Abstract
Isolated liver tuberculosis is still considered a rare condition and atypical clinical presentation challenges the clinical
acumen of the treating physician. There is difficulty in reaching the correct preoperative diagnosis of a nodular hepatic
tuberculosis that presents as a space-occupying lesion. It is usually unsuspected and confused with primary or metastatic
carcinoma of the liver. In this report, we describe a rare case of isolated    liver tuberculosis without pulmonary spread.

Keywords: S0L in Liver . Liver tuberculosis

[BSMMU J 2009; 2(2): 88-89]

Address for Correspondence: Dr. Zulfiqur Rhaman Khan,
Hepatobiliary Surgery, Associate Professor Department of Surgery,
BSMMU, Email: khanzulfiqur@hotmail.com

showing  pancreatic calculi in the head region with mild
dilation of the MPD. Computed tomography of the abdomen
showed multiple hypodense lesions in  the right lobe of the
liver (Figures 1-2) with pancreatic stones and enlarged head
of the pancreas suggestive of chronic pancreatitis with mass
lesion on the head of the pancreas with possible hepatic
metastasis.Upper GIT endoscopy  and colonoscopy
revealed normal findings.

Fig.-1: Axial CT scan showing a multiloculated, cystic
mass in the right  lobe of the liver.

Fig.-2: CT guided FNAC of the liver



CT guided FNAC of the liver was done Fig.-2.
Histopathological report revealed granulomatos tissue with
areas of caseous necrosis and classic tubercles on the
background of hepatocytes.No malignant cells were seen.

The patient was discharged with anti TB including
Isoniazid 300mg/day, rifampicin 600mg/day, pyrazinamide
1500mg/day and ethambutol 1500mg/day were
administered for two months and isoniazid 300mg/day and
rifampicin 600mg/day were subsequently administered for
four months. Patient also was getting  insulin and metformin
for diabetes.After treatment, the patient was followed up
for eight months without encountering any
problem.Follow up CT also revealed resolution stage.

Discussion:
There are three forms of hepatic tuberculosis. Diffuse
hepatic involvement with pulmonary or miliary tuberculosis
is the most common form seen in 50% to 80% of patients
dying of pulmonary tuberculosis. Diffuse hepatic
infiltration without recognizable pulmonary involvement
is the second form.Our case was in the second form. The
third very rare form presents as a focal/local tuberculoma
or abscess. ILT is the rarest form of local hepatic
tuberculosis 5. Kok et al  reported an overall incidence of
0.3% for isolated hepatic tuberculosis6. Hepatic
tuberculosis lesions that appear as masses larger than
2mm in diameter are referred to as macronodular and
pseudotumoural tuberculosis. On the basis of imaging
examinations alone, these lesions are virtually
indistinguishable from many other focal lesions of the
liver, such as hepatocellular carcinoma, metastases and
Hodgkin’s disease, so pathological examination is
necessary for diagnosis 3.

Isolated hepatic tuberculosis results from tubercle bacilli
gaining access to the portal vein from a microscopic or
small tubercular focus in the bowel. The clinical
presentation of ILT is so rare and atypical that it challenges
the clinical acumen of the treating physician2.

The difficulty is reaching a correct preoperative diagnosis
of nodular hepatic tuberculosis that presents as a space-
occupying lesion. It is usually unsuspected and confused
with primary or metastatic carcinoma of the liver, as in our
case. Radiological findings of hepatic tuberculosis are not
specific although multiple hypodense lesions have been
described on CT scan in cases of macronodular
tuberculoma of the liver 7.In our case we have also seen
the same CT features. The radiologic diagnosis of hepatic
tuberculoma is difficult and histopathologic diagnosis is
required to distinguish tuberculosis from
lymphoproliferative disorder, metastatic deposits and
other granulomatous disease like sarcoidosis and fungal
infection. Establishing the diagnosis is not easy, especially

if there is no history of previous tubeculosis exposure.
The definitive diagnosis could be done with tests on
histological and bacteriological evidence of tuberculosis.
The histological picture of hepatic tuberculoma is usually
that of a large epitehloid tumour composed of conglomerate
tubercles with central caseation necrosis. Langerhans-type
gaint cells may be found in the granuloma and are
surrounded by lymphohistiocytic cells, plasma cells and
eosinophils 8. In view of the nonspecific presentation and
imaging appearance of the disease, a high index of
suspicion is required to obtain a preoperative diagnosis 9.
In this case, the diagnosis was established by USG guided
FNAC. A  PCR assay can be done for identification of
Mycobacterium tuberculosis in liver biopsy specimens.
The importance of establishing the correct diagnosis
cannot be overstated, since untreated abdominal
tuberculosis carries a 50% mortality rate 10,11.

Conclusion:
Preoperative diagnosis of isolated liver tuberculosis that
presents as space occupying lesions is difficult. It is mostly
confused with primary or metastatic carcinoma of the liver.

References:
1 . Bangroo AK, Malhotra AS. Isolated hepatic tuberculosis. JIAPS

2005; 10: 105-107.

2 . Singh D, Singh S, Raut SB, Karmarkar SJ. Isolated liver
tuberculosis: a case report. Pediatr Surg Int 2004; 20: 727-28.

3 . Vimalraj V, Jyotibasu D, Rajendran S. Macronodular hepatic
tuberculosis necessitating hepatic resection: a diagnostic
conundrum. Can J Surg 2007; 10;50.

4 . Nampoory MR, Halim MM, Shreedharan R, al-Sweih NA,
Gupta RK, Costandi JN. Liver abscess and disseminated
intravascular coagulation in tuberculosis. Postgrad Med J
1995;71:490-92.

5 . Purl AS, Nayyar AK, Vij JC. Hepatic tuberculosis. Ind J Tub
1994; 41: 131-34.

6 . Kok KY, Yapp SK. Isolated hepatic tuberculosis: report of
five cases and review of the literature. J Hepatobiliary Pancreat
Surg 1999; 6: 195-98.

7 . Kumar V, Pandey D. Isolated hepatosplenic tuberculosis.
Hepatobiliary Pancreat Dis Int 2008; 7: 328-30.

8 . Tan TC, Cheung AY, Wan WY, Chen TC. Tuberculoma of the
liver presenting as a hyperechoic mass on ultrasound. Br J
Radiol 1997; 70: 1293 -95.

9 . Debnath PR, Tripathi R, Kandpall D, Kumar B, Malik E,
Sharma SB. Isolated tubercular liver abscess in children treated
with percutaneous isoniazid infusion. Indian J Tuberc 2007;
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1 0 . Chen HC, Chao YC, Shyu RY, Hsieh TY. Isolated tuberculous
liver abscesses with multiple hyperechoic masses on ultrasound:
a case report and review of the literature. Liver Int 2003; 23:
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1 1 . Alcantara-Payawal DE, Matsumura M, Shiratori Y. Direct
detection of Mycobacterium tuberculosis using polymerase
chain reaction assay among patients with hepatic granuloma.
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