Diagnostic Challenge: Concurrent Amoebic, Tuberculous, and Pyogenic Liver Abscesses in a Single Patient Following Laparoscopic Cholecystectomy

Abstract

Background: Liver abscesses are uncommon but potentially life-threatening conditions that may arise from bacterial, parasitic, or mycobacterial infections. Concurrent infection with amebic, pyogenic, and tuberculous organisms within a single hepatic abscess is exceedingly rare and presents a major diagnostic and therapeutic challenge. Case Presentation: A 42-year-old female presented with progressive right upper abdominal pain, pleuritic discomfort, fever, and weight loss six months after an uneventful laparoscopic cholecystectomy. Initial ultrasonography demonstrated minimal perihepatic fluid collection, and conservative management was initiated. Subsequently, worsening symptoms prompted contrast-enhanced computed tomography, which revealed a ruptured hepatic abscess in segment VI with subcapsular extension, peritoneal thickening, and ascites. Ultrasound-guided pigtail drainage was performed. Laboratory evaluation demonstrated positive amebic serology, pus culture growth of Staphylococcus aureus, and detection of Mycobacterium tuberculosis by GeneXpert from the abscess fluid. The patient was successfully managed with drainage, metronidazole therapy, and antitubercular treatment, resulting in complete clinical recovery. Conclusion: This case highlights the importance of maintaining a broad differential diagnosis in patients presenting with delayed hepatic complications following abdominal surgery. Simultaneous amebic, pyogenic, and tuberculous liver abscesses are extremely rare and require multimodal diagnostic evaluation and individualized multidisciplinary management. Key words: Liver abscess; Tuberculous liver abscess; Amebic liver abscess; Pyogenic liver abscess; Laparoscopic cholecystectomy; GeneXpert; Mixed hepatic infection