Case presentation
24 years old Nepalese male with no past medical history presented to our emergency department with two months history of epigastric pain. the pain is dull in nature, intermittent, moderate in severity, radiating to his back, sometimes increased by food intake. After that he started to developed fever sometimes associated with chills, and yellowish discoloration of his eyes ten days before his presentation to the hospital. He also reported 10 Kg weight loss for the last two months accompanied by loss of appetite.
On presentation, he was febrile with low-grade fever other vitals were stable. On examination, he was jaundiced, but not pale or cyanosed, with no signs of chronic liver disease. His abdomen was soft with mild epigastric tenderness, no hepatosplenomegaly, no palpable masses, and no flank tenderness. The examination of other systems was unremarkable. His lab on presentation showed normal leukocyte count, normal hemoglobin, and platelet count. coagulation profile was unremarkable. Urea and creatinine both were normal. his total bilirubin was high 62 umol / L, mainly direct 48 umol /L, alkaline phosphatase was 234 U/L, alanine transaminase (ALT) was 115 U/L, aspartate transaminase was 86 U/L (AST). Albumin was low 30 gm /L, amylase was high 87 U/L and lipase was normal. C-reactive protein was high 102 mg/L. His interferon-γ  release assay (Quantiferon TB Gold) test was positive. HIV and hepatitis tests both were negative. blood cultures showed no growth. Tumor markers CA 19-9 and alpha fetoprotein (AFP) both were normal.
His chest x-ray was unremarkable. Initially his ultrasound abdomen showed a hetero echoic cystic lesion measuring 4.3 x 3.9 cm is noted in the pancreatic head with peripheral vascularity (Figure 1a). Liver shows coarse echotexture. Mild intrahepatic biliary radical dilatation noted in the left lobe (Figure1b). No focal lesion. CBD is dilated measuring 9.9 mm. No obvious stone could be imaged in the visualized parts of the CBD.
He underwent MRI abdomen and MRCP which showed a relatively well-defined lobulated heterogenous T2 hyperintense necrotic lesion measuring 3 x 5.2 x 5.6 cm is noted involving the pancreatic head and the caudate lobe of the liver, displacing the adjacent structures. It shows peripheral thin enhancing and T2 hypointense rim and some internal enhancing septations with diffusion restriction of its central fluid contents and wall is also noted. This most likely represents a large abdominal cold abscess arising from a conglomerate necrotic peripancreatic / portacaval lymph nodal mass which has further extended to the pancreatic head and the caudate lobe of the liver. Two small adjacent peripherally enhancing cystic lesions in the segment VIII of the liver are noted which appear bright on the DWI, likely representing microabscesses. The necrotic abscess is compressing the CBD and causing moderate upstream CBD (about 13 mm) and mild intrahepatic duct dilatation. The radiologist suggested considering Tuberculosis infection as a first diagnosis.
CT abdomen showed Redemonstrations of lesion that was seen in MRI images which involving mainly the hepatic caudate lobe extending to porta hepatis, peripancreatic and pancreatic head, suggestive of abscess (tubercouls), with other adjacent necrotic lymph nodes in the upper abdomen. Tiny hepatic lesions in segment VIII likely microabscesses, and inflammatory changes in segment VI. Mass effect on the CBD (with upstream dilatation) and portal vein (Figure 2). CT chest was unremarkable.
He underwent Endoscopic ultrasound (EUS) with upper GI endoscopy for aspiration of the abscess and definitive diagnosis. EUS showed Intrahepatic bile ducts were dilated. There were multiple large lymph nodes with anechoic areas inside (necrotic LNs) in the liver hilum, para-aortic, para-duodenal areas.
Pancreatic parenchyma had diffused stranding and hyperechogenic foci. A cystic mass lesion measuring 40 x 40 mm was seen between the liver hilum and pancreatic head. The cystic mass had internal echogenicity, abutting liver parenchyma and pancreatic head, and was compatible with an abscess. CBD was normal but it was not possible to follow CBD due to the compression of the cystic mass. CHD was slightly dilated. A fine-needle aspiration from the
abscess was performed using a 19G FNA needle. Approximately 20 ml of grey-yellowish colored pus was aspirated from the abscess. TB culture, TB PCR, AFP stain, cytopathology and bacterial culture was sent. Later on, his AFP smear and PCR came positive for acid-fast bacilli (Mycobacterium tuberculosis), and the fluid culture showed Scanty growth Stenotrophomonas maltophilia treated with trimethoprim-sulfamethoxazole for 7 days. The diagnosis of pancreatic and liver tuberculous abscesses was made based on the above findings and results, then subsequently the patient was treated with anti-tuberculous therapy (ATT) which include Isoniazide, Rifampicin, Ethambutol, and Pyrazinamide. He showed a good clinical response to the ATT.