IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Disseminated Tuberculosis with Splenic Tuberculosis Abscess Rupture A Rare Presentation TaoQian Tang1, YongHsiang Hsu2, and Jen-Jyh Lee3 1 Gastroenterology, Department of Internal Medicine, 2Department of Pathology, and 3Chest Medicine, Department of Internal Medicine, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan, Republic of China
A 45-year-old HIV-negative man was admitted with left-sided abdominal pain. The first set of abdominal computed tomography (CT) scans revealed a splenic density suggestive of abscess formation. A chest X-ray also showed suspected cavitary changes at the left upper lobe. This was confirmed by chest CT (Figure 1A). Patient was admitted to pulmonary ward for further evaluation and management. On the third day after admission, the patient developed acute-onset diffuse abdominal pain associated with rigidity. Emergent CT (Figure 1B) showed splenic abscess rupture, ascites accumulation, and surrounding fat stranding formation. Emergent splenectomy and drainage were performed. Gross pathology showed spleen with abscess rupture (Figure 1C). Microscopic examination showed granulomatous inflammation, and Ziehl-Neelsen staining demonstrated acid-fast bacilli (indicated by arrows in Figure 1D). Patient had a stable recovery and completed a 9-month regimen of antituberculosis medications (isoniazid, rifampicin, and ethambutol).
Discussion Splenic tuberculosis is extremely rare and is usually associated with HIV or disseminated tuberculosis. Splenic tuberculosis abscess formation with abscess rupture is rarer still (1). Very few case reports exist worldwide. In otherwise healthy adults (especially in developing nations with high tuberculosis prevalence rates) who present with splenic abscesses or lesions, tuberculosis should remain high on the differential (2). n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. 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.
2. Zhan F, Wang CJ, Lin JZ, Zhong PJ, Qiu WZ, Lin HH, Liu YH, Zhao ZJ. Isolated splenic tuberculosis: A case report. World J Gastrointest Pathophysiol 2010;1:109–111.
Author Contributions: T.T. collated and analyzed data and wrote and edited the manuscript; Y.H. provided guidance for pathology specimens and edited the manuscript. J.-J.L. conceived the study, analyzed data, and wrote and edited the manuscript. All authors made substantial contributions to the analysis and interpretation of the data and to the drafting of this paper. All authors approved the final version of the manuscript. Am J Respir Crit Care Med Vol 190, Iss 7, pp 829–830, Oct 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201406-1189IM Internet address: www.atsjournals.org
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Figure 1. (A) Chest computed tomography (CT) showing a thin-wall cavity in left upper lobe and sporadic fibrocalcifications in both lungs. (B) Abdominal CT showing splenic abscess rupture, ascites accumulation, and surrounding fat-stranding formation. (C) Cut section of spleen showing large necrotic mass with rupture. (D) At 3400 magnification, Ziehl-Neelsen staining of spleen section demonstrating the presence of acid-fast bacilli (arrows).
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American Journal of Respiratory and Critical Care Medicine Volume 190 Number 7 | October 1 2014
A 45-year-old HIV-negative man was admitted with left-sided abdominal pain. The first set of abdominal computed tomography (CT) scans revealed a splenic density suggestive of abscess formation. A chest X-ray also showed suspected cavitary changes at the left upper lobe. This was confirmed by chest CT (Figure 1A). Patient was admitted to pulmonary ward for further evaluation and management. On the third day after admission, the patient developed acute-onset diffuse abdominal pain associated with rigidity. Emergent CT (Figure 1B) showed splenic abscess rupture, ascites accumulation, and surrounding fat stranding formation. Emergent splenectomy and drainage were performed. Gross pathology showed spleen with abscess rupture (Figure 1C). Microscopic examination showed granulomatous inflammation, and Ziehl-Neelsen staining demonstrated acid-fast bacilli (indicated by arrows in Figure 1D). Patient had a stable recovery and completed a 9-month regimen of antituberculosis medications (isoniazid, rifampicin, and ethambutol).
Discussion Splenic tuberculosis is extremely rare and is usually associated with HIV or disseminated tuberculosis. Splenic tuberculosis abscess formation with abscess rupture is rarer still (1). Very few case reports exist worldwide. In otherwise healthy adults (especially in developing nations with high tuberculosis prevalence rates) who present with splenic abscesses or lesions, tuberculosis should remain high on the differential (2). n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. 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.
2. Zhan F, Wang CJ, Lin JZ, Zhong PJ, Qiu WZ, Lin HH, Liu YH, Zhao ZJ. Isolated splenic tuberculosis: A case report. World J Gastrointest Pathophysiol 2010;1:109–111.
Author Contributions: T.T. collated and analyzed data and wrote and edited the manuscript; Y.H. provided guidance for pathology specimens and edited the manuscript. J.-J.L. conceived the study, analyzed data, and wrote and edited the manuscript. All authors made substantial contributions to the analysis and interpretation of the data and to the drafting of this paper. All authors approved the final version of the manuscript. Am J Respir Crit Care Med Vol 190, Iss 7, pp 829–830, Oct 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201406-1189IM Internet address: www.atsjournals.org
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
829
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 1. (A) Chest computed tomography (CT) showing a thin-wall cavity in left upper lobe and sporadic fibrocalcifications in both lungs. (B) Abdominal CT showing splenic abscess rupture, ascites accumulation, and surrounding fat-stranding formation. (C) Cut section of spleen showing large necrotic mass with rupture. (D) At 3400 magnification, Ziehl-Neelsen staining of spleen section demonstrating the presence of acid-fast bacilli (arrows).
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