Both leprosy and tuberculosis (TB) are known to have similar geographic endemicity. In the setting of coinfection, interferon-gamma release assays (IGRAs) to detect latent TB can be falsely positive. We report a case of leprosy with a positive IGRA and asymptomatic active pulmonary TB. Minocycline and dapsone therapy was initiated during the workup for TB and changed to rifampin (Rif), isoniazid, pyrazinamide, and ethambutol, with the addition of dapsone once coinfection was confirmed. Our review of the literature revealed a preponderance of coinfection reported with borderline and lepromatous disease. Ten patients were diagnosed with leprosy as the first infection; 7 of these patients (70%) were treated with Rif before TB diagnosis, and 70% (7/10) of coinfected patients were on steroids. If treatment for leprosy is a consideration before ruling out active TB, then minocycline may temporarily replace the Rif. The dire implications of Rif monotherapy in undiagnosed coinfection may warrant chest radiography with or without sputum microbiology as routine initial workup for all leprosy cases.

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INTRODUCTION: Pyogenic liver abscess (PLA) is a bacterial infection of the liver parenchyma with reported mortality of 6-14%. Early detection is vital to reduce overall morbidity and mortality. Due variability in clinical presentation, a high index of suspicion is necessary to avoid delay in diagnosis and treatment. Intra-abdominal infections such as diverticulitis or pathologic conditions of the biliary tract are the most common etiologies of PLA but micro-perforations in the setting of recent polypectomy leading to bacterial seeding through the portal circulation may account as an under-reported precipitant. CASE DESCRIPTION/METHODS: A 63-year-old male with history of chronic alcohol abuse who was admitted to the ICU on broad spectrum antibiotics after developing acute respiratory failure requiring mechanical ventilation and septic shock. The patient had several days of vague abdominal pain which led to acute worsening with encephalopathy. Initial evaluation in the ED revealed temperature of 106.2 and laboratory results revealed WBC 27.8, lactic acid of 3.6, procalcitonin level 52 ng/mL, alkaline phosphatase 131, AST 90, and ALT 65. CT of the abdomen and pelvis revealed multiloculated cystic mass in the dome of right liver measuring 8.6 cm × 8.1 cm x 7.2 cm. It was noted that patient had underwent a screening colonoscopy approximately three weeks prior to admission and multiple polyps were removed with a hot snare in the ascending, descending and sigmoid colon. Admission blood cultures revealed polymicrobial bacteremia and grew streptococcus and E. coli. Due to concern for underlying liver abscess from recent bacterial seeding from polypectomy, patient underwent IR guided drainage and placement of drain which relieved purulent fluid that cultures eventually became positive for Streptococcus intermedius. Despite appropriate antibiotic coverage, patient had persistent fevers and required transfer to hepatobiliary service for definitive surgical management. Patient underwent hepatic lobectomy and laparoscopic marsupialization of the liver abscess with dramatic improvement of fever curve and leukocytosis. DISCUSSION: PLA in the setting of recent colonoscopy is a known phenomenon, however the incidence is unclear. As colorectal cancer screening rates continue to increase in practice, awareness of the development of PLA in the setting of immunocompromised patients must be highlighted. Patient counseling on this potentially fatal complication should occur especially to immunocompromised patients.

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