Hepatic tubercular abscess due to paradoxical TB-IRIS during anti-tubercular therapy with concurrent drug-induced liver injury: a case report

Abstract

Background: Anti-tubercular therapy (ATT) is essential for treating tuberculosis but can sometimes cause liver injury and immune-mediated inflammation. The simultaneous occurrence of severe drug-induced liver injury (DILI) and a paradoxical immune reaction like immune reconstitution inflammatory syndrome (IRIS) is very rare, especially in patients without HIV.

Case Presentation: A 55-year-old man with sputum AFB and GeneX pert-confirmed pulmonary tuberculosis presented seven weeks after initiation of anti-tubercular therapy (ATT) with high-grade fever, jaundice, and abdominal pain. Laboratory evaluation revealed marked hyperbilirubinemia (total bilirubin 12.2 mg/dL) with moderately elevated liver enzymes. Imaging studies demonstrated a large hepatic abscess accompanied by ascites and pleural effusion. ATT was discontinued due to suspected drug-induced hepatotoxicity. The patient was managed with supportive care and broad-spectrum antibiotics. A subsequent liver biopsy revealed granulomatous hepatitis consistent with tuberculosis. After normalization of liver function tests, ATT was cautiously reintroduced in a stepwise manner, beginning with Ethambutol, followed by gradual addition of other first-line anti-tubercular agents. Oral Prednisolone was also administered as adjunctive therapy.

Management and Outcome: Following reintroduction of anti-tubercular therapy, the patient showed marked clinical improvement. The fever subsided, appetite improved, and body weight increased from 36 kg to 39 kg. Liver function tests demonstrated significant recovery, with total bilirubin decreasing to 2.8 mg/dL. Follow-up imaging revealed resolution of the hepatic abscess with residual fibrotic changes.

Conclusion: This case illustrates a rare coexistence of anti-tubercular therapy (ATT)–induced liver injury and a paradoxical inflammatory reaction manifesting as a tuberculous hepatic abscess. Early recognition of this dual pathology is essential to avoid misinterpretation as treatment failure or isolated drug-induced hepatotoxicity. Careful monitoring, gradual reintroduction of ATT, and the use of corticosteroids can lead to full recovery and prevent unnecessary interruption of therapy.

J Shaheed Suhrawardy Med Coll 2025; 17(1): 99-103