Splenic tuberculosis (splenic TB) is extremely uncommon, with no demarcating symptoms or abnormal imaging findings. As a result, it is likely to be misdiagnosed as splenic carcinoma, splenic abscess, lymphoma, rheumatic fever, or another condition. Although isolated splenic tuberculosis is uncommon, secondary involvement in miliary TB is common. If there is no history of tuberculosis in other organs, the misdiagnosis rate is high. We present the presentation, diagnosis, treatment, and literature review in this case report.
Case study: splenic tuberculosis
A 29-year-old man with human immunodeficiency virus (HIV) infection arrived at the emergency department with a 2-week history of left-sided abdominal pain. Six months prior to his presentation, he had been diagnosed with HIV infection and non-drug-resistant pulmonary tuberculosis, for which he had begun antiretroviral and four-drug antituberculous therapy. However, soon after his diagnosis, his antituberculous regimen was reduced to only rifampin and isoniazid. The left upper quadrant of the abdomen was tender to palpation in the current case. The viral load was 1778 copies per millilitre (reference value, 20), and the CD4 cell count was 119 per cubic millimetre. An enlarged spleen with numerous hypodense lesions was revealed by computed tomography of the abdomen (Panel A).
To rule out cancer, a splenectomy was performed.
The spleen was grossly examined and revealed numerous necrotic nodules with purulent discharge (Panel B). An examination of the histopathology revealed granulomatous inflammation with caseous necrosis (Panel C) and acid-fast bacilli (Panel D, arrowheads). A tissue culture came back negative. The tissue was tested for Mycobacterium tuberculosis using a real-time polymerase chain reaction, which confirmed the diagnosis of splenic tuberculosis. Pyrazinamide and ethambutol were reintroduced into the patient’s antituberculous regimen, and she completed 9 months of four-drug therapy.
Diagnosis and prognosis
Tuberculosis is a multi-system disease, with 90% of cases originating in the lungs, whereas isolated splenic tuberculosis, as described here, is a rare form of extrapulmonary TB. According to some experts, the number of reported cases of the disease in China is less than 100. Patients with AIDS or who are otherwise immunocompetent are at a high risk of splenic TB. Although Winternitz (1912) classified splenic TB as either primary or secondary, some researchers believe that all patients with splenic TB have previously been infected with tubercle bacillus in other organs.
There are no specific symptoms that can be used to diagnose splenic tuberculosis. Anaemia, elevated ESR, increased CPR, and a positive OT test is all examples of useful laboratory data. Ultrasound examination is easy, non-invasive, and beneficial. Miliary TB, nodular TB, tuberculous spleen abscess, calcific TB, and mixed-type TB are the five pathomorphological classifications for splenic TB.
A CT scan can also aid in the diagnosis, particularly in the case of a splenic abscess. It does, however, have some limitations. On the one hand, many conditions can present with multiple, hypodense splenic lesions on CT, such as malignant lymphoma, metastatic cancer, echinococcal cysts, hemangioma, or even infectious diseases due to frequent fever. Our patient could be suffering from a fungus infection. Candida is the most commonly involved fungus in fungal splenic abscesses, which are becoming more common, particularly in immunocompromised patients. However, CT cannot reveal the nature of splenic lesions. Typical nodules on the splenic capsule, on the other hand, are usually too small to be detected easily by a CT scan.
A splenic needle biopsy is an important method of diagnosis
This can be followed by a splenic aspiration puncture with image guidance. Caseation, granuloma of epitheloid cells, and Langhan’s cells are typical manifestations. Pathological evidence for diagnosis includes biopsy specimens from the cervical lymph node, lymphonodi coeliac, hydroabdomen, and pyocelia. In other cases, small nodules may be missed on needle biopsy, necessitating laparotomy or even splenectomy. So far, histopathological examination remains an excellent method of confirming the diagnosis. However, because of its invasive nature, many patients are hesitant to accept it. As a result, patients with the disease are frequently misdiagnosed or have their diagnosis delayed.
Laparoscopy has been used to diagnose splenic tuberculosis, and it has proven to be a minimally invasive approach that avoids unnecessary splenectomy. It is advised for any type of splenic biopsy.
Treatment of splenic tuberculosis, like treatment of pulmonary tuberculosis, must adhere to the following principles: timely treatment in combination, regularly and properly throughout the entire course, whether or not an operation is performed. Tuberculosis treatment should last at least 6 months. If an operation is performed, standard anti-tuberculosis medication should be taken both preoperatively and postoperatively.
Source: NEJM
