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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 53-56

Isolated tuberculous splenic abscess in a HIV-positive patient


1 Department of Radiology, Federal Neuropsychiaric Hospital, Maiduguri, Borno State, Nigeria
2 Department of Medicine, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria

Date of Submission09-Jul-2015
Date of Acceptance30-Nov-2015
Date of Web Publication12-Feb-2016

Correspondence Address:
Ballah Akawu Denue
Department of Medicine, University of Maiduguri Teaching Hospital, Maiduguri, PMB 1414, Borno State
Nigeria
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DOI: 10.4103/2384-5147.176323

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  Abstract 

Tuberculous splenic abscess is a rare cause of pyogenic splenic abscess and occurs most often in the setting of an immunosuppressive state. It is a life-threatening condition associated with high mortality without prompt management. The diagnosis can be challenging as it has no characteristic clinical and radiological findings. Hence high index of suspicion, imaging studies including ultrasound-guided aspiration of the abscess under aseptic technique is helpful in its diagnosis. We report a 32-year-old patient with HIV infection who presented with 5 weeks history of abdominal pain, fever, anorexia, and significant weight loss. Abdominal ultrasound scan showed splenomegaly with multiple areas of mixed echogenicity. About 30 ml of foul smelling, creamy dark brown diagnostic, and therapeutic aspirate drained under trans-abdominal ultrasound scan guidance yielded positive for Mycobacterium tuberculosis (TB) under culture. Our patient died on the 12 th day of admission before bacteriology result. Tuberculous Splenic abscess could be fatal it not promptly managed; it should be considered in patients presenting with fever and abdominal pain especially in the setting of HIV infection. Due to lack of characteristic clinical and imaging findings, it poses a serious diagnostic dilemma with attendant consequences as occurred in our case. Ultrasound-guided aspiration of the abscess under aseptic technique is helpful in its diagnosis. Empiric anti-TB therapy should be considered in patients that failed to respond to broad-spectrum antibiotics in highly endemic areas.

Keywords: Abscess, HIV infection, splenic tuberculosis


How to cite this article:
Ahmed A, Denue BA, Hammagabdo A. Isolated tuberculous splenic abscess in a HIV-positive patient. Sub-Saharan Afr J Med 2016;3:53-6

How to cite this URL:
Ahmed A, Denue BA, Hammagabdo A. Isolated tuberculous splenic abscess in a HIV-positive patient. Sub-Saharan Afr J Med [serial online] 2016 [cited 2021 Nov 28];3:53-6. Available from: https://www.ssajm.org/text.asp?2016/3/1/53/176323


  Introduction Top


Splenic abscess is an uncommon but often severe and life-threatening clinical condition, autopsy studies have established its incidence at between 0.14% and 0.7%. [1],[2] Only approximately 600 cases have so far been reported in the literature. [3] Isolated tuberculous splenic abscess, a form of atypical extrapulmonary tuberculosis (TB) is even a rarer clinical entity, with about five reported cases among immunocomitent individuals till date. [4],[5],[6],[7],[8] It occurs most often in the immunocompromised state; mostly occurs in patients with immunosuppressed conditions such as HIV infection. [9] Splenic TB can occur in two forms: Most commonly as part of disseminated disease through military dissemination or seldom as isolated form. Diagnosis of isolated TB is difficult and often delayed because of imprecise clinical manifestation. [9]

The reported mortality rate is up to 47%, and can potentially reach 100% without prompt treatment; however, with appropriate management mortality can decrease to <10%. [10] Prompt imaging investigations (computed tomography scanning, ultrasonography, and magnetic resonance imaging) facilitates early diagnosis and guides treatment, thus improving the prognosis. [11],[12] However, there are substantial overlaps of image finding between various splenic lesions making precise diagnosis a herculean task. [12] Diagnosis can be challenging in sub-Saharan Africa that bears the most world burden of TB-HIV co-infection. In view of the rarity of isolated splenic TB, we report a case of isolated splenic tuberculous abscess in antiretroviral therapy (ART) naïve HIV-positive patient.


  Case Report Top


A 32-year-old HIV-positive patient presented with 5 weeks history of excruciating abdominal pain more severe in the left hypochondrium and flank, nausea, anorexia, high-grade intermittent fever, lethargy, and significant weight loss. However, this was not associated with a cough, chest pain, or diarrhea. He neither had contact with any person with a chronic cough, TB diagnosis nor consumed unpasteurized milk. The patient was diagnosed HIV-positive 13 months before presentation on September 11, 2010, but was yet to commence ART on account of high CD4 count and absence of AIDS-defining illness. Patient CD4 count on presentation was 374 cells/μl. His clinical condition continued to deteriorate despite empiric antibiotics that included tablet amoxicillin-clavulanic acid 625 mg twice daily for 1 week, tablet erythromycin 500 mg qds for 10 days, and analgesic (tablet ibuprofen 400 mg twice daily, tablet voltaren sodium 50 mg twice daily, tablet acetaminophen 1 g pro re nata (PRN)) before the presentation.

On examination, he looked ill, weak, dehydrated and in painful distress. He was febrile (38.5°C), pale, but acyanosed, anicteric, and had no peripheral lymphadenopathy. The abdomen was flat with generalized tenderness on superficial tenderness; more severe in the left lumbar region. The spleen was 4 cm palpable below the left costal margin and tender. The liver, and kidneys were not palpably enlarged, and he had no ascites.

His laboratory results showed a hemoglobin concentration of 6 g/dl (11-14.5 g/dl), total white cell count of 9.6 × 10 9 /L (4-11 × 10 9 /L) and differential count of neutrophils of 70% (40-70%) monocyte of 5% (2-10%), lymphocyte 25% (20-45%), eosinophils count of 0% (1-6%) and erythrocyte sedimentation rate of 110 mm in the 1 st h, platelets count of 223 × 10 9 /L. Liver function tests, electrolytes and urea/creatinine were all within normal limits. Plain abdominal and chest radiograph were normal. However, trans-abdominal ultrasound scan as depicted in [Figure 1] and [Figure 2] showed enlarged spleen (a span of 13 cm) with multiple irregular areas of mixed echogenicity (the largest measure 3 cm × 3 cm). The posterior acoustic enhancement was noted but no calcification. The liver, biliary ducts, gallbladder, pancreatic, bed and both kidneys were normal in position, size, and echo pattern. There was no para-aortic lymph node enlargement. Ultrasound-guided aspiration yield about 30 ml of foul-smelling dark brown creamy pus. Stains for acid-fast Bacilli by the Ziehl-Neelsen method was negative, however, culture (bacteriological) using the Lowenstein-Jensen medium later yielded significant growth of Mycobacterium TB. The patient's clinical condition continued to deteriorate despite fluid resuscitation and conservative management including broad-spectrum antimicrobials (intravenous ceftriazone 1 g 12 hourly, intravenous metronidazole 500 mg 8 hourly, per oral trimethoprim-sulfamethoxazole 960 mg daily). The patient died on the 12 th day of admission.
Figure 1: (a and b) Splenic ultrasound showing multiple irregular areas of mixed echogenicity suggestive of an abscess

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Figure 2: Ultrasound scan image of the patient spleen showing a multiple irregular, anechoic areas with some internal echoes within them, suggestive of an abscess

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  Discussion Top


Splenic tuberculous abscesses are rare but important atypical presentation of TB and should be considered in patients with abdominal pain and pyrexia of unknown origin (PUO). [13] The splenic involvement is often as a result of disseminated TB. However, there are reports of isolated splenic involvement also especially in the setting of immunosuppresion such as HIV infection as in our case. Patients with HIV/AIDS are at particular risk for TB, the risk of extrapulmonary involvement increases with advancing immunosuppression. [14],[15],[16] Although our patient with CD4 count of 374 cells/μl was ineligible for ART according to the National Guidelines adopted from WHO (CD4 count >350 cells/μl) with no evidence of any AIDS-defining illness) as at time of presentation, he was none the less at risk as the defects in cellular immunity that exposes to TB in HIV infection is both quantitative and qualitative. [17]

The clinical manifestations of TB splenic abscess are usually nonspecific but may include; PUO, anorexia, malaise, fatigue, abdominal pain, and tender splenomegaly. Diagnosis of isolated splenic TB is difficult and is often delayed due to imprecise clinical manifestation. [11],[13],[15],[17] The documented sonographic features include; solitary or multiple hypoechoic (87%) or anechoic (13%) lesions of varying sizes and shapes, outlined in most cases by irregular walls. In longstanding cases, there may be calcification of the wall. [12],[13],[16],[18] Wall calcification was absent in our patient, a pointer to the fact that the abscess was likely to have been of recent onset.

Tuberculous splenic abscess poses a diagnostic challenge as its clinical, and radiological features may mimic other splenic lesions such as pyogenic abscess, fungal abscess, infarcts, cysts, and metastasis. A pyogenic abscess usually appears on ultrasound scan as a poorly defined hypoechoic lesion depending on the degree of proteinaceous fluid; while fungal abscesses usually appear as multiple small hypoechoic lesions with a characteristic target sign in immunocompromised patients. Splenic cysts are usually solitary, well-defined, asymptomatic [15],[18],[19] and usually seen in patients with hemoglobinopathies and embolic diseases of cardiovascular origin. These cysts are usually wedge in shape with their bases adjacent to capsule and apex pointing towards the hilum. Metastasis to the spleen is very rare, often ill-defined, multiple, small, and delineated. In tuberculous splenic abscess, the lesions are extensive and tend to progress on serial scanning unless properly managed. In our patient, the most likely radiological differentials would be fungal and tuberculous abscesses, however, imaging alone is not diagnostic, so we opted for ultrasound-guided aspiration and histology. [12],[13]

Imaging studies are justified in all suspected cases of splenic abscess. Patients with sonographic features suggestive of the splenic abscess should have an ultrasound-guided aspiration and drainage. This will assist in prompt diagnosis and management, especially in developing countries, where abdominal TB is common and more expensive imaging techniques are not readily available and neither affordable. [19]

Treatment of proven splenic abscess includes; splenectomy, image-guided percutaneous drainage, and antibiotics/anti-TB therapy depending on the cause. However, splenectomy is associated with predisposition to fatal sepsis especially due to encapsulated organisms and hematological abnormalities. Therefore, conservative management is the treatment of choice provided that the infective focus could be eradicated. Ultrasound scanning allowed for close monitoring and the opportunity for percutaneous drainage. Few complications are associated with percutaneous drainage of splenic abscess including; subcapsular hematoma, sepsis and hemodynamic compromise. [15],[20],[21] Our patient had therapeutic and diagnostic drainage of 30 ml of foul-smelling dark brown creamy pus under the aseptic procedure. It is unlikely that he had complications of the procedure as he was placed on prophylactic antibiotic (intravenous ceftriazone 1 g 12 hourly for 5 days and intravenous metronidazole 500 mg 8 hourly for 5 days) shortly before the procedure. Repeat abdominal ultrasound scan 24 h after procedure did not show evidence of subcapsular hematoma. However, our patient clinical condition continued to deteriorate despite antibiotic, analgesic, and intravenous fliud. He died on the 12 th day of admission. The definitive diagnosis of the isolated tuberculous splenic abscess was done a postmortem after the demise of the patient. We encountered several challenges and diagnostic limitations in the management of this patient that include a delay in making TB diagnosis due to lack of facility for a rapid test, as turnaround time of culture of Mycobacterium took 8 weeks. The patient was too weak for diagnostic laporatomy. Therefore, prompt definitive management was not instituted. Furthermore, late commencement of ART in a patient with low CD4 count is a risk factor for extrapulmonary TB including splenic abscess.


  Conclusion Top


Tuberculous splenic abscess is a life-threatening clinical condition, and should be considered in patients presenting with fever, abdominal pain, and splenomegally especially in the setting of HIV infection. It has no specific clinical and radiological findings, hence poses a serious diagnostic dilemma. Delay in diagnosis is associated with high mortality as in the index case. Ultrasound-guided aspiration of the abscess under aseptic technique was helpful in its diagnosis. Empiric anti-TB therapy should be considered in patients that failed to respond to broad-spectrum antibiotics in highly endemic areas.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC, et al. Clinical characteristics and prognostic factors of splenic abscess: A review of 67 cases in a single medical center of Taiwan. World J Gastroenterol 2006;12:460-4.  Back to cited text no. 1
    
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Dede F, Dogan E, Demir M, Sener D, Kös M, Tad M, et al. Unusual presentation of tuberculosis as a splenic mass. Tohoku J Exp Med 2006;210:79-82.  Back to cited text no. 11
    
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Ho PL, Chim CS, Yuen KY. Isolated splenic tuberculosis presenting with pyrexia of unknown origin. Scand J Infect Dis 2000;32:700-1.  Back to cited text no. 13
    
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Sharma MP, Bhatia V. Abdominal tuberculosis. Indian J Med Res 2004;120:305-15.  Back to cited text no. 14
    
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Llenas-García J, Fernández-Ruiz M, Caurcel L, Enguita-Valls A, Vila-Santos J, Guerra-Vales JM. Splenic abscess: A review of 22 cases in a single institution. Eur J Intern Med 2009;20:537-9.  Back to cited text no. 15
    
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Sharma SK, Smith-Rohrberg D, Tahir M, Mohan A, Seith A. Radiological manifestations of splenic tuberculosis: A 23-patient case series from India. Indian J Med Res 2007;125:669-78.  Back to cited text no. 16
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Zolopa A, Andersen J, Powderly W, Sanchez A, Sanne I, Suckow C, et al. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: A multicenter randomized strategy trial. PLoS One 2009;4:e5575.  Back to cited text no. 17
    
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Tikkakoski T, Siniluoto T, Päivänsalo M, Taavitsainen M, Leppänen M, Dean K, et al. Splenic abscess. Imaging and intervention. Acta Radiol 1992;33:561-5.  Back to cited text no. 18
    
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Debeuckelaere S, Schoors DF, Buydens P, Du Ville L, Spapen HD, Reynaert HM, et al. Splenic abscess: A diagnostic challenge. Am J Gastroenterol 1991;86:1675-8.  Back to cited text no. 19
    
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Hui JP, Kwok KM, Lai MH, Loke TK, Luk WH, Chan JC. Tuberculous splenic abscess: An unusual presentation. J HK Coll Radiol 2007;10:19-22.  Back to cited text no. 20
    
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Zhan F, Wang CJ, Lin JZ, Zhong PJ, Qiu WZ, Lin HH, et al. Isolated splenic tuberculosis: A case report. World J Gastrointest Pathophysiol 2010;1:109-11.  Back to cited text no. 21
    


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