A CASE OF RIGHT SIDED PLEURAL EFFUSION WITH LIVER ABSCESS

INTRODUCTION

Tuberculosis may involve any organ in the body but involvement of liver is uncommon. 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. Here, I’m presenting case of RIGHT SIDED PLEURAL EFFUSION WITH LIVER ABSCESS...

NAME: MR.SUBRAMANIYAN     AGE: 56 Yrs
ADDRESS: VEDARANYAM, TAMIL NADU.

PRESENT COMPLAINTS AND HISTORY:

 1. H/O ABDOMINAL PAIN - 1 MONTH DURATION, PAIN IN THE

RIGHT HYPOCHONDRIAL REGION, PAIN CONTINOUS AND IS

 PRICKING TYPE, NONRADIATING TYPE, WAS RELEIVED BY

MEDICATIONS. THERE WAS NO ASSOCIATED NAUSEA OR

VOMITING.

2. H/O FEVER- 1 MONTH DURATION, HIGH GRADE WITH

CHILLS AND RIGOR, CONTINUOS AND WITH EXCESSIVE SWEATING, NOT ASSOCIATED WITH JOINT PAINS,NOT ASSOCIATED WITH HEADACHE, NOT ASSOCIATED  WITH SKIN RASHES, NOT ASSOCIATED WITH BURNING SENSATION OF URINE.

3. H/O BREATHLESSNESS OF 2 DAYS DURATION. Class IV

SUDDEN ONSET,

WITH PROFUSE SWEATING AND ORTHOPNEA.

HE WAS BROUGHT TO V.M.M.C.

PAST HISTORY: NOT A DIABETIC OR HYPERTENSIVE, NO H/O

TUBERCULOSIS, MALARIA, HEPATITS, TYPHOID FEVER.

 PERSONAL HISTORY:  ALCOHOLIC FOR PAST 20 YRS. TAKES

180 ML PER DAY. NON SMOKER.

.

TREATMENT HISTORY: PATIENT WAS EVALUATED WITH USG ABD

AND WAS TREATED AS AMOEBIC LIVER ABSECESS IN PRIVATE

HOSPITAL WITH IV ANTIBIOTICS AND OTHER MEDICATIONS.

 HIS FEVER SUBSIDED BUT CONTINUED TO HAVE MINIMAL

ABDOMINAL PAIN. HE WAS DISCHARGED AFTER 1O DAYS.

ON FOLLOW UP HE HAD THE SAME MINIMAL ABDOMINAL PAIN

AND WAS GIVEN ANTACIDS AND PROTON PUMP INHIBITORS.

GENERAL EXAMINATION:  CONSCIOUS, ORIENTED,

DYSPNEIC AND TACHYPNEIC, ACCESSORY MUSCLES OF

RESPIRATION ACTING,

PALLOR PRESENT, NOT ICTERIC,

GRADE 1 CLUBBING PRESENT,

NO LYMPHADENOPATHY,

NO PEDAL EDEMA.

VITALS- 

PULSE- 100/min, REGULAR, NORMAL VOLUME AND CHARACTER.

BLOOD PRESSURE- 130/90mmHg IN RIGHT UPPER LIMB,

RESPIRATION- 40/mt, ABDOMINOTHORACIC,

JUGULAR VENOUS PRESSURE- NOT ELEVATED.

TEMP-FEBRILE

EXAMINATION OF RESPIRATORY SYSTEM: TRACHEA SHIFTED

TO LEFT SIDE, INTERCOSTAL BULGING PRESENT, VOCAL

FREMITUS REDUCED ON RIGHT INFRACLAVICULAR, MAMMARY,

INFRAMAMARY, AXILLA, INFRAAXILLARY AND INFRASCAPULAR

AREA. PERCUSSION WAS STONY DULLNOTE IN ABOVE AREAS.

ON AUSCULTATION, BREATH SOUND REDUCED ABOVE AREAS.

NO ADVENTIOUS SOUNDS.

EXAMINATION OF ABDOMEN: SOFT, TENDERNESS PRESENT

OVER RIGHT HYPOCHONDRIUM, HEPATOMEGALY 2 FINGER

BREADTH FROM RIGHT INTERCOSTAL SPACE, SMOOTH AND TENDER. NO ENLARGED SPLEEN.

OTHER SYSTEMS: NORMAL

CLINICAL IMPRESSION-    MASSIVE   PLEURAL EFFUSION RIGHT SIDE

                                                  HEPATOMEGALY             - DUE TO LIVER ABSCESSS

INVESTIGATIONS:

BLOOD ROUTINE

             HB-9.2gm%, TLC-26,100 Cells/cumm

             DC P 69%, L 23%, E 8%,

             ESR- 88mm/hr

URINE ROUTINE

            ALB-NIL, SUGAR-NIL, PUS CELL- NIL,

            BILE SALT- NIL, BILE PIGMENT-NIL.

RBS- 140mg%,

RFT- UREA-22 mg%, CREATININE- 1.2mg%.

LFT –

            T.BILIRUBIN 1.4mg%,

            D.BILIRUBIN-0.3mg%,

            SGOT-16 IU/L

            SGPT-34 IU/L,

            ALP- 476 IU/L,

            TOTAL PROTEIN-6.2

            ALB-2.0,

.

WIDAL TEST- NEGATIVE,

HBSAG-NEGATIVE,

HIV 1 &2- NEGATIVE.

E.C.G- SINUS TACHYCARDIA, OTHERWISE NORMAL.

PERIPHERAL SMEAR- DIMORPHIC ANEMIA WITH TOXIC GRANULES

IN NEUTROPHILS.

PLEURAL FLUID-

            COLOUR-STRAW COLOURED,

            SUGAR-80mg/dl

            PROTEIN- 4.9g/dl

            TLC-7,200, NEUTROPHIL- 74%, LYMPHOCYTE-21%

            C/S-NO GROWTH AFTER 48 HRS,

            CYTOLOGY- NEUTROPHILS AND MESOTHELIAL CELLS IN

                        PROTINACEOUS BACKGROUND, NO EVIDENCE OF

                        MALIGNANT CELLS.

            AFB- NEGATIVE.

PLEURAL FLUID C/S- NO GROWTH.

PLEURAL FLUID ADA ASSAY- 41.80U/L

USG ABDOMEN-

HEPATOMEGALY WITH MULTIPLE COMPLEX CYSTIC MASSES IN BOTH LOBES OF LIVER OF SIZE OF 2-9cm 

THE LARGEST MEASURE 85 mm OF SIZE

IN RIGHT LOBE.

CHEST X RAY-    MASSIVE RIGHT SIDED PLEURAL EFFUSION.

LIVER ASPIRATION

SAMPLE-

Frank PUS

ASPIRATE AFB STAINING - NEGATIVE.

FINAL DIAGNOSIS:

                      PYOGENIC LIVER ABSCESS WITH TUBERCULAR PLEURAL EFFUSION.

 DIFFERENTIAL DIAGNOSIS-

PLEURAL EFFUSION AND LIVER ABSCESS

            OF TUBERCULOUS ORIGIN.

PYOGENIC LIVER ABSCESS WITH SYMPATHETIC

            PLEURAL EFFUSION.

DISCUSSION:

                      AS THERE ARE MULTIPLE ABSCESSES WITH FRANK PUS, IT IS OF PYOGENIC ORIGIN.EVENTHOUGH THE CULTURE IS NEGATIVE, I STRONGLY SUSPECT PYOGENIC ORIGIN AS THE PATIENT HAS BEEN TREATED WITH ANTIBIOTICS PREVIOUSLY COMING TO OUR HOSPITAL.

SINCE THERE IS A MASSIVE EFFUSION ON THE RIGHT SIDE WHICH IS AN EXUDATIVE EFFUSION AND THE PLEURAL ADA IS ALSO ELEVATED, IT IS TUBERCULOUS EFFUSION. BUT THERE IS NEUTROPHILIA IN PLEURAL FLUID WHICH CAN BE PRESENT IN EARLY CASE OF TUBERCULOUS EFFUSION.

LITERATURE:

Liver involvement has been reported in 10 to 15% of patients with pulmonary tuberculosis and it is a common finding in patients with disseminated tuberculosis2-4. 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 in diameter is much less common and cavitary hepatic tuberculosis is least encountered.

The clinical and radiological features of tuberculous liver abscess may mimic pyogenic or amoebic liver abscess and the diagnosis depends on presence of caseating granulomatous lesion in liver biopsy and/or presence of AFB in such material.

Hepatic involvement is undoubtedly a part of widespread tuberculosis and diffuse lympho- hematogenous spread is the most likely origin of hepatic disease.

TO CONFIRM THE DIAGNOSIS:                            

PLEURAL FLUID CULTURE FOR AFB

PLEURAL BIOPSY.

LIVER BIOPSY WITH PUS CULTURE FOR AFB—to prove for tubercular origin of abscess.

REFERENCES:

Ø       Kapoor VK, Abdominal tuberculosis: The Indian contribution, Indian .J Gastroenterol, 1998; 17;14I

Ø       . Nilyanand, Agarwal HK, Singh, Manmect: Tuberculous liver abscess.J Assoc Physicians India, 2000;48;244

Ø      . Roy R, Goyal RK Gupta N., Tuberculous liver abscess - a case report J Assoc Physicians India, 2000;48;241

BY,

        V.SARASWATHY,

         FINAL YR MBBS PART2,

         VINAYAKA MISSIONS MEDICAL COLLEGE,

          KARAIKAL.

GUIDED BY

                  Dr. EZHILNILAVAN, M.D [GEN MED]

                  ASST PROFEESOR,

                   DEPT. OF GENERAL MEDICINE,

                  VINAYAKA MISSIONS MEDICAL COLLEGE, 

                  KARAIKAL.