Lobectomy Reveals Co-infection of Streptococcus Anginosus and Extrapulmonary Tuberculosis

Abstract

Isolated Mycobacterium Tuberculosis (TB) infection of the liver without signs of other organ involvement in immunocompetent patients is extremely rare and accounts for <0.5% of all forms of primary TB. We present a case of a young male whose diagnosis was only achieved after multiple admissions,treatment of Streptococcus Anginosus (SAG), and surgical lobectomy which finally revealed the masquerader. Only a handful of cases have ever been reported of pyogenic abscesses occurring due to this co-infection. A 24 year old Pakistani male was admitted for fever and weakness after returning from a recent trip to Pakistan. He had three weeks of right upper quadrant pain. ROS revealed he had night sweats, fatigue, weakness, and 15lb weight loss. He denied recent sick contacts. Vitals included a temperature of 101.3F, HR 100 bpm. RR 12 and BP 108/57 mmHg. Labs were notable for WBC 14,400/uL,Hb 12.8g/dl,ALT 38U/L,AST 30U/L,Alk. phos 326U/L,total bilirubin 1.1mg/dL,INR 1.5.2329_A Figure 1. MRI of Hepatomegaly and Abscess2329_B Figure 2. Ultrasound of Liver Abscess2329_C Figure 3. Portal Vein ThrombosisAbdominal CT and Ultrasound revealed left liver lobe abscesses with thrombosis of the left portal vein. CXR was negative. PPD was inconclusive due to history of exposure during childhood and sputum AFB tests were negative. Liver biopsy showed granulomatous inflammation and cultures revealed (SAG). Left portal vein, liver FNA, blood cultures, acid-fast bacilli smears were negative for TB. He was discharged with 10 days of antibiotics but continued to decompensate. Liver biopsy was negative for malignancy. He deteriorated requiring left lobe hepatectomy and cholecystectomy. Initial pathology results from liver showed caseating granulomas, but stain was negative for AFB. 16 days later TB was isolated and treated. The possibility of co-infections causing pyogenic abscesses must not be excluded. A case series evaluating 618 patients with hepatic TB revealed microscopic analysis of liver visualizing AFB had a median sensitivity of 25%, caseating granulomas 68%, and PCR had a sensitivity of 86%. Obtaining tissue to diagnose extrapulmonary TB is the gold standard. The sensitivities of culture and PCR are 77% and 72%. SAG is a commensal of the GI tract and can produce a liver abscess. One study showed 51% of their cases associated with SA. Isolated tubercular liver abscess without any other foci of infection is an extremely rare presentation of tuberculosis with a prevalence of only 0.34%. Isolated Tuberculosis liver abscess (TLA), with a prevalence of just 0.34%, must always remains in your differential.