Hepatic tuberculosis is a common cause of pyrexia. [1,2] Amoebic liver abscess is also a common cause of pyrexia. Both diseases can cause a solid S.O.L. (space occupying lesion) in the liver. I present below a case report of a hepatic tuberculoma.

Material and Method

A middle aged 45-year-old lady hailing from U.P. was seen by me in my clinic for pyrexia of three weeks' duration and hepatic discomfort with loss of appetite. She had an enlarged liver (3-cm) which was slightly tender. She had received full antiamoebic drugs (including a course of Inj. Emetine and Metronidazole) without any relief.

Her biochemical investigations were all normal except mild anaemia of 10 gms. raised alkaline phosphatase (192 M units) and raised E.S.R. (104 mm.). I.H.A. test was negative. Isotope scan showed cold area in right lobe. Sonography showed this area to be hyperechoic (Fig. 1). Mantoux test was strongly positive (26 mm.).

A course of antikochs was started. After a period of two months, with full therapeutic doses of Isoniazid, Rifampicin and Ethambutol, there was only slight improvement.

Laparotomy was done. A solid mass the size of a ping pong ball (with surrounding tubercles of varying sizes) (Fig. 2) was seen in the liver with typical caseation and adhesions to the surrounding peritoneum and intestines. This mass had to be enucleated. The histopathology appearance of the mass was consistent with diagnosis of tuberculous granuloma. Culture for A.F.B. sent from this tissue was positive. Patient recovered, whilst antikochs drugs were continued after the operation.

Discussion

Solid S.O.L. can occur in the liver in amoebic or tuberculous infections (Fig.3). Unfortunately, serological tests for amoebiasis have not become available all over our country. Also, I.H.A. test, done commonly, is very sensitive but not specific. Not only could it be falsely positive, even when positive, at least one more test, like the C.I.E.A. test, or the Fluorescence antibody test should also be done.

Similarly, in our country, in adults, the Mantoux test does not help in diagnosis. So often, we see 12-16 mm. Positive, without any active kochs focus in the body.

A therapeutic test for amoebiasis in this situation may be worthwhile. But it must be kept in mind that solid amoebic abscess is a rare type of amoebic abscess. Also, solid tuberculoma is a rare type of hepatic tuberculosis, where not only will the full antikochs treatment be required, but surgical enucleation of this mass may also be required, since in our opinion, this much mass, unlike in the case of brain tuberculoma, would not dissolve with antikochs drugs.

Therefore, patients having a solid S.O.L. in the liver should be investigated thoroughly in the medical centres. Serological tests for amoebiasis must be done. Laparoscopy can also be done in such patients and the mass can be biopsied. In other cases, the presence of small tubercles elsewhere in the liver or specially on the peritoneum or the other viscera would click the diagnosis as against an amoebic pathology. Adhesions around the mass would possibly differentiate from lymphoma or other malignant deposits.

Summary

A case of solid tuberculoma of the liver as a case of S.O.L. has been presented. It has been discussed as to how closely it can mimic solid amoebic abscess. It has also been shown that such patients may need surgical treatment, when at laparotomy, the whole mass can be enucleated.

Acknowledgement

I am grateful to Dr. N.H.Keswani, Medical Director, Jaslok Hospital & Research Centre, Bombay, for allowing me to publish this material.

Reference

1. KAPOOR O.P. : Hepatic Tuberculosis, Bulletin of the Jaslok Hospital & Research Centre, 2 : 32 : 1967
2. LELE R.D., KAPOOR O.P., KAKKAR V.C. & ARUN CHITALE; Fever of Obscure Origin, Bulletin of the Jaslok Hospital & Research Centre, 1 : 18 : 1976