An Uncommon Site, a Common Foe: Isolated Hepatic Tuberculosis in a HIV Positive Adult

Extrapulmonary tuberculosis such as hepatic tuberculosis, while rare, is becoming increasingly prevalent, especially in HIV endemic regions such as India. Hepatobiliary tuberculosis manifests either as isolated hepatic or isolated biliary, or combined hepatobiliary tuberculosis. We present a 28-year-old male, a known case of HIV on anti-retroviral therapy, with a history of smoking, alcoholism, and intravenous drug use, presenting with abdominal pain and vomiting for the past one week, with associated fever and fatigue for the past two weeks. On examination, he had pallor, icterus, and a tender abdomen. Initial baseline investigations revealed anemia, thrombocytopenia, raised prothrombin time/international normalized ratio, and raised alkaline phosphatase. Ultrasound and contrast-enhanced computed tomography of the abdomen revealed multiple liver abscesses, which were drained surgically. Chest X-ray was normal. Ziehl-Neelsen (ZN) staining of the aspirate was positive for acid-fast bacilli, and the MGIT culture flagged positive in 15 days. MPT64 rapid assay of the MGIT broth was also positive, suggestive of Mycobacterium tuberculosis complex (MTBC). The CD₄ count was 108/µl. The patient's clinical condition improved on initiation of anti-tubercular therapy (ATT). Clinicians in TB and HIV endemic countries, such as India, must maintain a high index of suspicion, especially among young patients presenting with liver abscess, as prompt diagnosis and initiation of ATT will lead to a significant reduction in morbidity and mortality.