Multiloculated Thoracoabdominal Tuberculosis: A Rare Radiological Presentation of Disseminated Tuberculosis

Introduction: Tuberculosis (TB) is more frequently found among high-risk populations such as immigrants, with HIV, incarcerated, and homeless individuals in the US. it is still a significant public health concern as diagnosis and presentation represent a challenge, especially as it is known to affect virtually any organ in the body with a broad range of unique presentations that may delay diagnosis. This is especially true regarding hepatic TB, with prevalence varying in each study but highly suggestive of underdiagnosis. Case Description/Methods: A 19-year-old male, without known past medical history, presented with a 2-month history of fever, cough, weight loss, and night sweats. The only high-risk factors was cohabitation with known multidrug-resistant TB. Vital signs at admission and physical exam were within limits. Labs were notable for normocytic anemia, normal white count, elevated inflammatory markers (high ferritin, thrombocytosis), HIV negative, and mildly deranged LFTs (AST, ALT, and ALP). Imaging revealed a right lung cavitary mass with bilateral pulmonary nodules, right pleural nodular thickening traversing diaphragm extending to the liver with subcapsular hepatic lobulated hypodensities. MRI spine showed C4 subligamentous enhancement with relative disc sparing, concerning Pott's disease. Sputum PCR and AFB smear were positive for M. tuberculosis, diagnosing pulmonary TB. IR-guided fluid samples of the subcapsular hepatic cultures were negative for TB but positive for AFB, suggesting hepatic TB. The patient was started on ethambutol, levofloxacin, rifampin, and pyrazinamide to complete a 9-month course and discharged with outpatient follow-up. Discussion: Hepatic TB can manifest as asymptomatic or with hepatomegaly, jaundice and RUQ pain. Further classified as miliary TB (usually asymptomatic, the most frequent), tuberculosis hepatitis (fever and hepatomegaly), and hepatobiliary TB. Diagnosis is challenging, should be considered in individuals from endemic areas with RUQ pain. Laboratory usually shows elevated ALP(as in our case) and GGT. CT with contrast/ triple phase are the preferred images to characterize the lesions. Whenever feasible, tissue biopsy with culture should be obtained (see Figure 1).Figure 1.: Multiloculated hepatic mass, consistent with hepatic tuberculosis.