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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 3  |  Page : 120-122

Splenic tuberculosis in immunocompetent patient: A case report and literature review


1 Department of Medicine, Hamad General Hospital, HMC, Doha, Qatar
2 Department of Medicine, Hamad General Hospital, HMC; Weill Cornell Medical College, Doha, Qatar
3 Department of Medicine, Hamad General Hospital, HMC; Weill Cornell Medical College; College of Medicine - Qatar University, Doha, Qatar

Date of Web Publication4-Oct-2018

Correspondence Address:
Dr. Fahmi Yousef Khan
Department of Medicine, Hamad General Hospital, HMC, Weill Cornell Medical/Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_34_18

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  Abstract 


Splenic tuberculosis (TB) is usually seen as part of disseminated TB, especially in immunocompromised patients. We report such a case in a 23-year-old immunocompetent male patient who presented with a 10-day history of left-sided abdominal pain and fever. Computed tomography (CT) of the abdomen showed an enlargement of the spleen with multiple hypodense lesions, some of them with septations, the largest measuring 6.9 cm × 5.4 cm, in addition to multiple lymph nodes. Chest X-ray showed left apical fibronodular infiltrate with prominent left hilar region suggestive of enlarge lymph node. Sputum for acid-fast bacilli was positive, and the patient was initiated on 4-drug anti-tuberculous treatment. The diagnosis of splenic TB was retrospectively confirmed based on a complete regression of the splenic lesions on the follow-up CT of the abdomen.

Keywords: Disseminated tuberculosis, immunocompromised patient, splenic tuberculosis


How to cite this article:
Neffati N, Khan FY, Elzouki AN. Splenic tuberculosis in immunocompetent patient: A case report and literature review. Libyan J Med Sci 2018;2:120-2

How to cite this URL:
Neffati N, Khan FY, Elzouki AN. Splenic tuberculosis in immunocompetent patient: A case report and literature review. Libyan J Med Sci [serial online] 2018 [cited 2018 Dec 13];2:120-2. Available from: http://www.ljmsonline.com/text.asp?2018/2/3/120/242731




  Introduction Top


Splenic tuberculosis (TB) is a rare form of extrapulmonary TB, which usually seen as part of disseminated TB, especially in immunocompromised patients.[1],[2] Their clinical and laboratory findings are nonspecific as they simulate other infectious diseases. The early diagnosis of this condition is crucial since a late diagnosis or that is overlooked can cause fatal complications.[2] Herein, we report a case of disseminated TB with spleen involvement to increase physician's awareness of this rare form of extrapulmonary TB in immunocompetent patients.


  Case Report Top


A 23-year-old Indian male patient with no reported significant medical history presented to the Accident and Emergency department with a 10-day history of left-sided abdominal pain and fever. Abdominal pain was dull in nature, moderate in intensity, radiating to the back, exaggerated by movement and relieved in sitting position, associated with low-grade fever and weight loss. He also reported a 1month history of dry cough.

On physical examination, the patient was looked ill, febrile with temperature of 38 × 2°C, pale but not jaundiced. Abdominal examination revealed a tender splenomegaly about 7 cm below costal margins, while the rest of his examination was unremarkable.

Laboratory investigations showed a microcytic hypochromic anemia with hemoglobin of 9, 8 g/dl. His white cell count, platelets, blood biochemistry, and liver function tests were within normal range, and HIV testing was negative.

The patient underwent an urgent ultrasound of the abdomen that revealed an enlarged spleen measuring 17 cm with multiple complex cystic lesions, the largest of which measured 5.3 cm × 5.2 cm [Figure 1]. Computed tomography (CT) of the abdomen showed an enlargement of the spleen with multiple hypodense lesions, some of them with septations, the largest measuring 6.9 × 5.4 cm, in addition to multiple lymph nodes in the perigastric, retrocaval, pericoeliac, precaval, hepatic, and preaortic regions [Figure 2] suggesting splenic infection. Chest X-ray showed left apical fibro-nodular infiltrate with prominent left hilar region suggestive of enlarge lymph node [Figure 3].
Figure 1: Abdominal ultrasound shows multiple complex cystic lesions, the largest of which measured 5.3 cm × 5.2 cm

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Figure 2: Abdominal computed tomography shows an enlargement of the spleen with multiple hypodense lesions

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Figure 3: Chest X-ray shows left apical fibro-nodular infiltrate with prominent left hilar region

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Based on these findings, the possible diagnoses were splenic pyogenic abscess, splenic TB abscess, and splenic lymphoma with superimposed infection. The patient was started empirically on broad-spectrum antibiotic (piperacilline/tazobactam) and was admitted and kept in a TB airborne isolation room. Sputum for acid-fast bacilli (AFB) was positive as well-purified protein derivative skin test. Therefore, the patient was diagnosed as disseminated TB with spleen involvement. Antibiotic was discontinued, and a 4-drug anti-tuberculous medication (isoniazid, rifampicin, ethambutol, and pyrazinamide) regimen was immediately initiated. On the following days, the fever and abdominal pain subsided and 2 weeks after admission, the repeated sputum smear for AFB was negative on 2 consecutive days. Hence, airborne isolation was suspended, and the patient was discharged on quadruple therapy for 2 months followed by two-drug regimen for another 4 months, and he was advised to follow the TB clinic regularly. Mycobacterium tuberculosis was grown after 32 days and was sensitive rifampicin and isoniazid. A 7-month follow-up abdominal CT showed a complete regression of the splenic lesions and a complete resolution of the symptoms. With this result, the diagnosis of disseminated TB with spleen involvement was made.


  Discussion Top


Splenic TB occurs in two forms, either primary or as part of disseminated TB, which is found mainly in patients with immunosuppressive disorders, such as hematologic abnormalities, diabetes mellitus, HIV infection, organ transplantation, and chronic steroid therapy.[1],[2] Although uncommon, case reports of splenic TB in immunocompetent patients are found both in the literature[3],[4] and in ours. Five morphological forms of splenic TB were described that included miliary, nodular, splenic abscess, calcified, and mixed with splenic abscess as in our case, being the most common.[1],[4]

Splenic TB is usually identified by radiologic investigations; however, fine-needle aspiration, splenic biopsy, or splenectomy is required to confirm the diagnosis. The specimen should be subjected to smear AFB, polymerase chain reaction, and culture methods for isolation of M. tuberculosis as well as histopathology examination for detection of caseating granulomas.[5],[6],[7] In our case, ultrasound and CT scan demonstrated findings, which were similar to those seen in any bacterial or fungal infections. A splenic biopsy was not performed since the sputum for AFB was positive, and the diagnosis of splenic TB was retrospectively confirmed after treatment completion and resolution of splenic lesions as shown by the complete regression of the splenic lesions on the follow-up CT of the abdomen, confirmed the diagnosis.

In fact, randomized controlled trials of splenic TB treatment have not been conducted, and most of the evidence are based on randomized controlled trials of pulmonary TB or case reports, and there is no consensus on the optimal duration of treatment. However, based on available data, antituberculous chemotherapy is the first line of treatment of splenic TB with a duration of 6–9 months.[6],[7],[8] Surgery may be appropriate in patients having spontaneous splenic rupture or failure of anti-tubercular treatment.[2],[6]


  Conclusion Top


Splenic TB should be included as one of the differential diagnosis of splenic mass in immunocompetent as well as immunocompromised patients from areas endemic for TB, especially when the patient presents with upper abdominal pain, fever, and splenomegaly. Antituberculous treatment is the first-line therapy with relatively good outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Imani Fooladi AA, Hosseini MJ, Azizi T. Splenic tuberculosis: A case report. Int J Infect Dis 2009;13:e273-5.  Back to cited text no. 1
    
2.
Kumar S, Pai AG, Tungenwar PN, Bhandarwar AH. Isolated primary tuberculosis of spleen – A rare entity in the immuno-competent patient. Int J Surg Case Rep 2017;30:93-6.  Back to cited text no. 2
    
3.
Adil A, Chikhaoui N, Ousehal A, Kadiri R. Splenic tuberculosis. Apropos of 12 cases. Ann Radiol (Paris) 1995;38:403-7.  Back to cited text no. 3
    
4.
Amin Soliman MA. Splenic tuberculosis – A rare case report. Glob J Med Clin Case Rep 2017;4:72-3.  Back to cited text no. 4
    
5.
Joshi S, Bankar M, Kagal A, Rane S, Bharadwaj R, Phadke M. Splenic tuberculosis – A rare case report. Internet J Med Update 2007;2:38-41.  Back to cited text no. 5
    
6.
Dixit R, Arya MK, Panjabi M, Gupta A, Paramez AR. Clinical profile of patients having splenic involvement in tuberculosis. Indian J Tuberc 2010;57:25-30.  Back to cited text no. 6
    
7.
Pottakkat B, Kumar A, Rastogi A, Krishnani N, Kapoor VK, Saxena R, et al. Tuberculosis of the spleen as a cause of fever of unknown origin and splenomegaly. Gut Liver 2010;4:94-7.  Back to cited text no. 7
    
8.
Masoodi I. Splenic tuberculosis: Report of two cases and literature review. BJMP 2017;10:a1001.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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