Tuberculosis in Cirrhosis: A Diagnostic and Therapeutic Challenge.

Tuberculosis (TB) continues to represent a major global health concern, particularly in high-burden countries such as India. In patients with cirrhosis, TB presents a distinct clinical challenge owing to cirrhosis-associated immune dysfunction and impaired bacterial clearance, which increase susceptibility to both primary infection as well as reactivation of latent disease. Additionally, cirrhosis alters the classical clinical presentation and radiological findings of TB, thereby contributing to diagnostic ambiguity. Conventionally, tuberculin skin test and interferon-gamma release assays, demonstrate reduced reliability in the setting of immune dysregulation. Typical radiological findings may be absent, and advanced imaging modalities such as PET-CT may offer additional diagnostic value when standard imaging techniques such as chest radiography, ultrasonography, or computed tomography fail to reveal characteristic abnormalities. Invasive diagnostic approaches, including cytology or tissue biopsy, remain the gold standard for definitive confirmation. Therapeutic management is particularly complex, as first-line anti-tubercular agents such as isoniazid, rifampicin, and pyrazinamide possess significant hepatotoxic potential and may precipitate hepatic decompensation. Consequently, treatment strategies must be individualized according to Child-Turcotte-Pugh or MELD scores, with careful balancing of effective TB control against the risk of drug-induced liver injury. Close biochemical monitoring and cautious drug reintroduction are essential. Future directions should focus on the development of safer therapeutic regimens, incorporation of novel agents with lower hepatotoxic potential, application of pharmacogenomic-guided treatment approaches, and formulation of consensus guidelines specifically tailored to this high-risk population. This review aims to comprehensively describe the epidemiology, underlying pathophysiological mechanisms, diagnostic complexities, and therapeutic considerations of tuberculosis in patients with cirrhosis.