S3491 A Rare Case of Hepatic Tuberculosis in an Immunocompetent Patient

Introduction: Abdominal tuberculosis comprises around 5% of all TB cases worldwide and includes involvement of the GI tract, peritoneum, lymph nodes and solid organs. Risk factors include cirrhosis, HIV, diabetes, malignancy and chronic corticosteroid use. In the setting of active or miliary TB, abdominal involvement may develop via hematogenously or lymphatically. Diagnosis of abdominal TB may be established by presence of M. tuberculosis in peritoneal fluids, a biopsy specimen of the involved site or via mycobacterial culture or NAAT testing. Case Description/Methods: We present a case of a 26-year-old man born in Guatemala with a history of polysubstance abuse. He presented with a 3 month history of progressive dyspnea, hemoptysis, night sweats, and weight loss. On exam, he was cachectic in appearance with decreased breath sounds and poor inspiratory effort. His LFTs on admission were noted to be elevated with AST/ALT 133/135 respectively. Alk Phos was also elevated to 271. CT AP on admission noted to have mild hepatomegaly with mildly enlarged retroperitoneal lymph nodes. Despite TB vaccination as a child, he was found to have NAAT positive TB. He subsequently started RIPE therapy with a significant increase in LFTs also seen in Table 1. His hospital course was complicated by non-immune mediated thrombocytopenia due to initiation of RIPE therapy further complicated by development of intraparenchymal and subarachnoid hemorrhage (Figure 1). Discussion: Although the incidence of tuberculosis is declining over the years with close to 10.6 million cases in 2021, abdominal tuberculosis is only seen in only around 5% of the infected population. Of that 5%, the immunocompromised population are more likely to have disseminated spread. Elevated LFTs may reflect the site of disease; involvement of the liver parenchyma may be reflected by elevated transaminases, while involvement of the porta or biliary ducts may be reflected by elevated Alk Phos and GGT. This case also shows how patients can develop this condition despite obtaining the BCG vaccination. It seems unlikely that the initiation of RIPE therapy led to the increase in liver enzymes to develop a drug induced liver injury. This patient remained on RIPE therapy while his AST/ALT was acutely elevated and continued to improve, suggesting that this treatment was possibly therapeutic for his liver. Our case describes the course of a vaccinated, immunocompetent, young man who presented with miliary tuberculosis infiltrating the liver, leading to decompensation.Figure 1.: CT Abdomen Pelvis with IV Contrast showing mild hepatomegaly and enlarged retroperitoneal lymph nodes. Table 1. - Noted are the patients liver enzymes (AST, ALT, Alk Phos, Total Bilirubin), starting from the day of admission, to the day of initiation if RIPE therapy and thereafter Admission Day 2 Day 3 (Initiation of RIPE Therapy) Day 10 Day 20 Day 30 AST 133 96 28 22 16 13 ALT 135 147 94 23 18 14 Alk Phos 271 323 394 1450 1187 395 Total Bilirubin 0.9 1.1 0.8 0.4 0.3 0.2