Case Report

Ind.J.Tub.; 2001,48,219

RIGHT SIDE PLEURAL EFFUSION AND LIVER ABSCESS

OF TUBERCULOUS ORIGIN
M.C. Dhar1, S. Chaudhuri2, S. Pain3, U. Balder4, T. J. Sau4, K. BasiT, D. Pal5 and S. R. Bagchi5

(Received on 1.5.2001; Revised Version received on 25.7.2001; Accepted on 30.7.2001)

Summary : Tuberculous liver abscess is rare and it may mimic amoebic liver abscess, pyogenic liver abscess or tuberculous
pseudo-tumour. A 68 year old male, non-hypertensive, non-diabetic, presented with features of right side pleural effusion.
Ultrasonography of abdomen showed liver abscess. A positive BACTEC culture and PCR for AFB in the pus aspirated
from the abscess confirmed the diagnosis of tuberculous liver abscess.

INTRODUCTION
Tuberculosis may involve any organ in the
body but involvement of liver is uncommon1. Most
patients with hepatic tuberculosis are of miliary type
consisting of widespread multiple granulomas but
focal hepatic tuberculosis in the form of liver abscess
is the least common. We are presenting a case of
tuberculous liver abscess and right side pleural
effusion.
CASE REPORT
BSB, 68 year old male, non-hypertensive,
non-diabetic patient was admitted in our unit on
13.01.2000 with the complaints of (i) Low grade
fever for 1 month, (ii) Pain in the right lower chest
and upper abdomen for 15 days and (iii) Respiratory
distress gradually increasing for 7 days. There was
no history of cough or expectoration, recent blood
transfusion, contact with a tuberculosis patient, nor
any history of drug intake or extra-marital sexual
exposure. On examination, the patient was
emaciated, had mild anaemia, but jaundice, oedema,
clubbing or cyanosis were absent. Pulse 100/ min,
regular, blood pressure 130/80 mm of Hg and no

lymphadenopathy. Examination of respiratory system

revealed features of pleural effusion on the right side
i.e. dull percussion note, absent breath sounds and
shifting of trachea to the left. Liver was palpable, 4
cm below right mid-clavicular line, firm in
consistency, and there was no splenomegaly;
abdominal lymph nodes were also not palpable.
Examination of cardiovascular and nervous
system was within normal limits. Ophthalmoscopic
examination revealed no abnormality including
absence of choroidal tubercle. About 500 ml of
straw coloured pleural fluid was aspirated.
Laboratory investigations revealed Hb 10.5
g%, TLC 9500/cmm N70 L29 El Ml, ESR 70mm
1 st hr, Urine and Stools-NAD, Blood Sugar
(F)83mg%, Urea 23mg%, Creatinine 0.5mg%,
LFT- Protein 6.7g%, Total Bilirubin 0.6mg%, SCOT
6.34U/L, SGPT 9.75U/L, Alkaline Phosphatase
10 KA Units; Mantoux test( 1:10000) +ve (18mm x
14mm); EL1SA for H1V -ve;VDRL-ve;Pleural fluid
- yellowish in colour, Protein 4g%, Sugar 56mg%,
Cell count 300/cmm, N25 L72 Mesothelial cells
3, PAP stain -ve, Smear for Gm stain & ZN

1 .Professor 2. Assistant Professor 3. RMO and Tutor 4. Medical Officer 5. Associate Professor
Department of Medicine, R G Kar Medical College, Calcutta
* Department of Medicine, Institute of Post-Graduate Medical Education and Research, Calcutta
Correspondence Dr M C Dhar, 53 A, Department of Medicine, R G Kar Medical College, Karbala Tank Lane, Calcutta 700 006

The Indian Journal of Tuberculosis

220

M . C. DAR ET AL.

stain revealed no organism; X-ray chest showed

right side pleural effusion (Fig. 1); ECG within
normal limits; ultrasonograph abdomen - liver
enlarged, with an elongated (110 mm x 42 mm) low
echogenic structure in the right lobe with thick well
defined wall, suggestive of liver abscess (Fig. 2),

echotexture of the rest of liver and spleen was

normal. The portal vein was 8 mm in diameter. Intrahepatic biliary channels were not dilated and there
was no free f l u i d in the peritoneal cavity. No
abdomin al lymph node enlargement could be
detected. There was evidence of right side pleural
effusion. USG guided aspiration of the abscess
brought out 60 ml of creamy pus, but no pathogenic
organism could be detected by Gm stain or ZN stain.
However, AFB culture by BACTEC method and PCR
were positive.
The patient was treated w i t h antituberculosis drugs, R 450 mg, H 300mg, E SOOmg
and Z 150mg for 1 month and he responded well to
tr eatmen t b u t he s u d d e n l y developed acu te
myocardial infarction and expired.
DISCUSSION

Fig. 1 Chest X-Ray showing right side pleural effusion

Fig. 2 USG Abdomen showing an elongated (110mm X 42

mm) low echogenic structure in the right lobe of the liver
with thick well-defined wall suggestive of liver abscess

The patient presented with pleural effusion

and the clinical features and aspirated fluid analysis
were suggestive of tubercular origin because the
pleural fluid analysis showed exudative effusion due
to chronic infection since the cell count was 300
cells/c.mm and 72% were lymphocytes and no
malignant cell could be detected. We performed USG
abdomen to find out the cause of hepatomegaly and
it was suggestive of an abscess. As the abscess was
solitary and the aspiration produced creamy but not
anchovy sauce type pus, which did not show growth
of any organism and was associated with exudative
pleural effusion, we suspected the abscess also to
be of tuberculous origin. A positive BACTEC culture
and PCR test confirmed the diagnosis of tuberculous
liver abscess.
Liver involvement has been reported in 10
to 15% of patients with pulmonary tuberculosis and
it is a common finding in patients with disseminated
tuberculosis 2-4 . Hepatic tuberculosis occurs in
several forms, the commonest being the miliary
variety with nodules from 0.5 to 2 mm in diameter
and the lesions larger than 2 mm are classified as
focal tuberculosis. The macronodular hepatic
involvement with tuberculous nodules of several cms
The Indian Journal of 'Tuherculosis

PLEURAL EFFUSION AND LIVER ABSCESS OF TUBERCULOUS ORIGIN

in diameter is much less common and cavitary

hepatic tuberculosis is least encountered2,3. The
clinical and radiological features of tuberculous liver
abscess may mimic pyogenic or amoebic liver
abscess or tuberculous pesudo-tumor5,6 and the
diagnosis depends on presence of caseating
granulomatous lesion in liver biopsy and/or presence
of AFB in such material.

body and abscess formation in the liver is uncommon

in hematogenous spread.
REFERENCES
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2.
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Hepatic involvement is undoubtedly a part

of widespread tuberculosis and diffuse lymphohematogenous spread is the most likely origin of
hepatic disease. In our case, tuberculous liver
abscess along with pleural effusion developed
probably due to hematogenous spread of bacilli from
primary site(lung) though there was no evidence of
miliary tuberculosis in the lung or elsewhere in the

221

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5.

6.

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