|Year : 2015 | Volume
| Issue : 2 | Page : 69-72
Tubercular splenic abscess: Two case reports with review of literature
Subhra Mitra, Mrinmoy Mitra, Satyajeet Sahoo, Bijan Kumar Ghosh
Department of Pulmonary Medicine, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||16-Jun-2015|
Kailash Bhawan, 41/2 Abinash Chandra Banerjee Lane, Beliaghata, Kolkata - 700 010, West Bengal
Source of Support: None, Conflict of Interest: None
Tubercular splenic abscess is an extremely rare entity among immunocompetent individuals. Here we describe two cases of tubercular splenic abscess in immunocompetent individuals, the first had to undergo emergency splenectomy for pain abdomen. The second case presented with pyrexia of unknown origin where pus aspirated from spleen stained positive for acid fast bacilli. Both had favorable response to anti-tubercular therapy. Tuberculosis although uncommon should be kept as a differential diagnosis of splenic abscess presenting with pain abdomen or pyrexia of unknown origin with multiple hypodense lesions in spleen on imaging.
Keywords: Abscess, extrapulmonary tuberculosis, immunocompetent, spleen
|How to cite this article:|
Mitra S, Mitra M, Sahoo S, Ghosh BK. Tubercular splenic abscess: Two case reports with review of literature. J Assoc Chest Physicians 2015;3:69-72
|How to cite this URL:|
Mitra S, Mitra M, Sahoo S, Ghosh BK. Tubercular splenic abscess: Two case reports with review of literature. J Assoc Chest Physicians [serial online] 2015 [cited 2020 Jul 7];3:69-72. Available from: http://www.jacpjournal.org/text.asp?2015/3/2/69/158872
| Introduction|| |
Tuberculosis (TB) is a systemic disease that presents with various clinical manifestations as pulmonary TB or extrapulmonary TB (EPTB). EPTB constitute 10-15% of all types of TB; among the extrapulmonary forms, splenic TB is extremely rare entity.  In majority of splenic TB cases its rarity makes it a misdiagnosis or delayed diagnosis. Here we are reporting two cases of tubercular splenic abscess with different presentations.
| Case Reports|| |
A 45-year-old male, nondiabetic and nonhypertensive, presented to our institute with pain in upper abdomen for preceding 2 months. There were no complaints of fever, cough, hemoptysis, chest pain, or shortness of breath. Bowel and bladder habits were normal. There was no history of any trauma in recent past. No contact history of TB was present. He was of average built with good nutrition and stable vitals. His body weight was 45 kg. His respiratory rate was 18/min with bilateral vesicular breath sounds. Abdomen was soft, but tenderness was present in left hypochondrium. The spleen was palpable 4 cm along its long axis, tender and firm in consistency, surface smooth, and movement with respiration was present, but no rub or bruit heard. No other organs were palpable. Examinations of other systems were unremarkable. His blood counts and biochemical parameters were within normal limits except elevated erythrocyte sedimentation rate (ESR) (60 mm/h Wintrobe's method). He was seronegative for human immunodeficiency virus by enzyme-linked immunosorbent assay test. Mantoux test with 5TU was positive with 18 mm induration. Chest skiagram was normal. Induced sputum and bronchoalveolar lavage were negative for acid-fast bacilli (AFB). Ultrasonography (USG) abdomen showed several hypoechoic foci in the spleen [Figure 1]a. Computed tomography (CT) abdomen revealed multiple, small, nonenhancing, hypodense, space-occupying lesions in central and peripheral locations suggestive of abscesses [Figure 1]b. Due to incremental pain abdomen, the patient was put up for emergency exploratory laparotomy. Open splenectomy was done with postoperative deep venous thrombosis (DVT) prophylaxis and pneumococcal vaccination. Histopathological examination of biopsied splenic lesions showed epithelioid granulomas with Langhans' giant cells [Figure 2]. The smear was stained negative with Ziehl-Neelsen (ZN) staining. He was prescribed with antitubercular therapy (ATT) under category I of Revised National Tuberculosis Control Program (RNTCP). Patient had an uneventful follow-up.
|Figure 1: (a) Ultrasonography (USG) abdomen showing several hypoechoic foci in the spleen. (b) Computed tomography (CT) abdomen revealing multiple small nonenhancing hypodense space occupying lesions in central and peripheral locations suggestive of abscesses|
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|Figure 2: Histopathological examination of biopsied splenic lesions showing epithelioid granulomas with Langhans' giant cells|
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A 27-year-old nondiabetic, normotensive, male attended our department with low-grade intermittent fever for preceding 8 months, anorexia, and weight loss. There were no complaints of cough, dyspnea, hemoptysis, chest pain, headache, dysuria, hematuria, altered bowel habits, joint pains, and rash. Bowel and bladder habits were normal. His wife took ATT from RNTCP for sputum smear positive pulmonary tuberculosis (TB) 5 years back. His body weight was 38 kg. His respiratory rate was 20/min with bilateral vesicular breath sounds. No lymph nodes were palpable. Gastrointestinal system examination revealed a soft abdomen with tenderness over both hypochondrium. Liver was palpable 3 cm along the midclavicular line, firm in consistency with sharp border, smooth surface, tender but nonpulsatile with a liver span of 15 cm, and no rub or bruit heard. Spleen was palpable 3 cm along its long axis, soft consistency, tender, smooth surface, and moved normally with respiration, without rub or bruit. No shifting dullness was elicited. Examinations of other systems were unremarkable. Testes were normal. His blood counts and biochemical parameters were within normal limits except elevated ESR (74 mm/h Wintrobe's method). He was seronegative for human immunodeficiency virus by enzyme-linked immunosorbent assay test. Mantoux test with 5TU was positive with 20 mm induration. Chest skiagram was normal. Induced sputum and bronchoalveolar lavage were negative for AFB. USG abdomen showed enlarged liver with multiple small hypoechoic space occupying lesions (about 10-11) scattered in both lobes of liver ranging from 1 to 3 cm. Rest of the liver parenchyma appeared normal. Spleen was enlarged 13.5 cm in its long axis. Multiple hypoechoic solid space occupying lesions (about 9-10) were seen scattered in splenic parenchyma. Periportal and paraaortic lymphadenopapathy were also found. Contrast-enhanced CT (CECT) abdomen revealed hepatosplenomegaly with multiple well-defined, rounded, nonenhancing, hypodense lesions suggestive of abscesses in both the liver and spleen [Figure 3]. Multiple small and large discrete nodes were seen in the retroperitoneum (left paraaortic, interaortocaval, and precaval locations). Bone marrow aspiration showed infective changes. USG-guided aspiration from a lesion in the spleen yielded pus and on smear showed degenerated neutrophils, lymphocytes, plasma cells, histiocytes, and epitheloid cells in a necrotic background. The smear stained positive for AFB [Figure 4]. He received ATT with category I regimen under RNTCP. The patient became afebrile within 14 days of initiation of ATT. He completed the treatment for 6 months and had a weight gain of 13 kg during this period.
|Figure 3: Contrast-enhanced CT (CECT) abdomen showing hepatosplenomegaly with multiple, well-defined, rounded, nonenhancing, hypodense lesions suggestive of abscesses in both the liver and spleen|
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|Figure 4: Smear from pus aspirated from splenic lesion showing degenerated neutrophils, lymphocytes, plasma cells, histiocytes, and epitheloid cells in a necrotic background and stained positive for acid-fast bacilli (AFB)|
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| Discussion|| |
Although EPTB constitutes more than 50% of all TB cases in human immunodeficiency virus (HIV)-affected individuals, it accounts for 15-20% among immunocompetents.  Abdominal TB encompassing gastrointestinal tract; peritoneum; omentum; mesentery; nodes; and other solid intraabdominal organs such as liver, spleen, and pancreas account for only 3% of all EPTB in immunocompetent individuals.  Peritoneal and mesenteric lymph node involvement predominate sometimes associated with solid organ involvement such as liver, however splenic involvement is rare. None of the 300 patients of abdominal TB described by Bhansali had splenic involvement.  Splenic TB is most commonly a part of miliary or disseminated TB and rarely an isolated phenomenon.  Spleen may be involved via the bloodstream, usually following reactivation of foci from a primary lung focus, although hematogenous spread may complicate active pulmonary TB or miliary TB. Contiguous spread from mesenteric lymph nodes, intestine, or fallopian tubes may also occur. Most of the reported cases of splenic TB were associated with immunocompromised conditions. However, there were also few cases where splenic TB was associated in immunocompetent patients. , Here we report two cases of tubercular splenic abscess, first one was isolated splenic involvement; but the second one had associated involvement of liver and regional lymph nodes. In both the cases, the patients were immunocompetent. Splenic abscess has a very low incidence (0.14-0.7% at autopsy)  and those of tubercular etiology are even more uncommon. Various mechanisms of formation of splenic abscess include hematogenous infection, contiguous infection, hemoglobinopathy, immunosupression (including HIV and chemotherapy), and trauma. As for tubercular splenic abscess, a probable explanation might be that the red pulp of the spleen is relatively devoid of phagocytic activity and helps the entrapped, slow-growing mycobacteria to escape from the reticuloendothelial system of spleen.  In majority of cases involvement of spleen is a part of disseminated TB, which may overshadow or overlap the clinical scenario according to other sites of involvement and very rarely asymptomatic.  In splenic TB the most common constitutional symptoms are fever, pain abdomen, anorexia, and weight loss. ,,, Tubercular splenic abscess may manifest with splenomegaly, fever of unknown origin, pain abdomen, and weight loss. , In our case series, the predominant presenting symptom of the first patient was abdominal pain, whereas, the second patient presented with fever, weight loss, and anorexia. The advent of USG and CT has facilitated an earlier intervention. It helps in giving a hint about the nature of the lesion, the site for aspiration or biopsy, and follow-up. On USG, solitary or multiple hypoechoic lesions represent tuberculomas, which may be necrotic or hemorrhagic; whereas, irregular anechoic lesions with thick and shaggy wall are more suggestive of tubercular abscess.  On CT, splenic TB has a characteristic appearance of solitary or multiple hypodense nodular areas.  The differentials of hypodense lesions on CT are various congenital, parasitic, and neoplastic cysts; abscesses, traumatic, sickle cell disease, infarction, hamartoma, sarcoidosis, hemangiomas, lymphomas, and metastatic deposits. Most pyogenic abscesses are unilocular and typically exhibita "rim-enhancement" of the outside-facing portion of the abscesses' wall. Gas formation within the abscess usually confirms pyogenic etiology. Fungal abscesses are mostly multifocal (up to 90%), smaller (<2 cm), and do not show rim enhancement. Tubercular abscesses are usually small (<2 cm), ill-defined with mild contrast-enhancement.  Radiologically, splenic TB has been classified into two forms, micronodular and macronodular, depending on whether it is smaller or larger than 10 mm.  Micronodular TB is more common and usually seen in disseminated systemic TB. If the resolutions of the nodules are below the capacity of the imaging technique, then they can be present as simply splenomegaly.  Macronodular splenic TB is rare and could manifest as a single abscess or multiple large nodules or multiple abscesses.  In our cases, both the patients presented with multiple, nonenhancing, space-occupying lesions suggestive of abscesses in CT scans. In first case, abscesses were found only in the spleen; whereas in the second case, along with spleen, liver was also involved. In all pulmonary and extrapulmonary cases definitive diagnosis of TB is made by isolating Mycobacterium tuberculosis bacilli from the site of involvement. In our first case we were unable to demonstrate the bacilli from the site, but we confirmed our diagnosis through histopathological examination. Unlike the first case, in second case we clearly demonstrated AFB in the fine needle aspiration sample from spleen. ATT is the first line for the management of splenic TB; whereas, surgery should be reserved for ruptured spleen or failure to medical intervention.  If an operation is carried out, standard antitubercular treatment should be taken preoperatively and postoperatively.  In our case series, we treated both cases with antitubercular drugs under RNTCP for 6 months. In first case as the patient presented with acute pain, abdomen splenectomy was performed followed by antitubercular treatment. In conclusion, we want to publish this case series of two cases of tubercular splenic abscess as they are very rare and their presentations are very much nonspecific like acute pain abdomen or fever of unknown origin. Often microbiological confirmation is very difficult in diagnosis of splenic TB and in that case histopathological confirmation is required. Although uncommon at present time, splenic TB should be included in the differential diagnosis of the patients presenting with fever of unknown origin, pain abdomen with splenomegaly, and hypodensities on imaging.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]