Splenic Tuberculosis

A47-year-old female was admitted with fever of unknown origin. Four months prior to admission, she was found to have inflammatory bowel disease associated with severe panuveitis and was started on infliximab and azathioprine. She had a positive tuberculin skin test with previous BCG vaccination. Chest computed tomography (CT) showed left hiliar calcified granulomas. Abdominal CT scan revealed an enlarged spleen with multiple millimeter-size hypodense nodules throughout the parenchyma (Fig. 1). Selective splenic artery embolization was done, and laparoscopic splenectomy was performed. Intra-operative findings were consistent with moderate splenomegaly and multiple whitish nodules all over the spleen (Fig. 2). Laparoscopic splenectomy was achieved with no peri-operative complications. Pathologic review of the specimen revealed multiple caseating granulomas, and a special preparation with Ziehl-Neelsen stain identified multiple acid-fast bacilli consistent with Mycobacterium tuberculosis. The patient was discharged satisfactorily on intensive antituberculous treatment with a four-drug regimen consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol.

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FIG. 1.

Multiple hypodense splenic nodules on abdominal computed tomography scan.

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FIG. 2.

Laparoscopic view of spleen.

Except in trauma, splenic pathology is rare and is represented mainly by benign or malignant lesions, infectious causes, and hematologic disorders. Splenic abscesses have been associated with different microorganisms, including aerobic bacteria (Streptococcus spp., Staphylococcus spp., Salmonella spp., Pseudomonas, Escherichia coli, Enterococcus spp., Klebsiella, and Proteus), anaerobic bacteria (M. tuberculosis and M. avium complex), and fungi [1]. Splenic tuberculosis represents an extremely rare entity; there are just small series and a few isolated case reports in the literature. Splenic infection by M. tuberculosis may occur as primary involvement of the spleen or during miliary tuberculosis [2]. Presenting symptoms may be related to systemic tuberculosis infection or to direct splenic involvement, which may produce left upper-quadrant pain, ascites, and splenomegaly [3]. The radiologic features are splenomegaly, a solitary mass, or multifocal hypodense nodular lesions [3].

In some scenarios, splenectomy represents both a diagnostic and a therapeutic intervention. There are case reports in which the diagnosis was made with a percutaneous biopsy, and patients were treated successfully with antituberculous drugs [4]. Laparoscopy is a minimally invasive approach for diagnosis or treatment for this rare condition [5].