A Case of Splenic Tuberculosis

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A Case of Splenic Tuberculosis

  1. 1. PROF.DR.G.SUNDARAMURTHY’S UNIT -DR.K.SENTHAMIZH SELVAN AN INTERESTING CASE OF FEVER
  2. 2. <ul><li>Saravanan </li></ul><ul><li>30yrs/male </li></ul><ul><li>manual labourer </li></ul><ul><li>thirvottriur </li></ul>CASE DETAILS
  3. 3. <ul><li>pt presented with </li></ul><ul><li>c/o fever - 2 months </li></ul><ul><li>H/O PRESENT ILLNESS : </li></ul><ul><li>- H/O fever -2 months,low grade,continuous fever , </li></ul><ul><li>not ass. With chills and rigor </li></ul><ul><li>- H/O vague left upper abd discomfort- 1 month , dull aching ,not radiating ,no agg & relieving factors </li></ul>HISTORY
  4. 4. <ul><li>H/O loss of weight ,around 10 kgs ,in the past 2 months. </li></ul><ul><li>H/O loss of appetite + </li></ul><ul><li>H/O easy fatiguability + </li></ul><ul><li>no h/o cough with expectoration / altered bowel habits </li></ul><ul><li>no h/o jaundice </li></ul><ul><li>no h/o abd distension,leg swelling </li></ul><ul><li>no h/o oral ulcers ,joint pains, swelling, discoloration of extremities ,joint stiffness </li></ul>
  5. 5. <ul><li>no h/o of skin rashes </li></ul><ul><li>no h/o bleeding diathesis </li></ul><ul><li>no h/o dysuria </li></ul><ul><li>no h/o seizures </li></ul><ul><li>no h/o altered sensorium </li></ul><ul><li>no h/o chest pain ,palpitation ,breathlessness </li></ul>
  6. 6. <ul><li>PAST HISTORY : </li></ul><ul><li>- not a known SHT/T2DM/BA/epileptic/CKD </li></ul><ul><li>- no h/o contact with open case of PT </li></ul><ul><li>- no h/o ATT </li></ul><ul><li>- no h/o blood transfusion/surgery </li></ul>
  7. 7. <ul><li>PERSONAL HISTORY : </li></ul><ul><li>- occasional alcoholic,not a smoker </li></ul><ul><li>- no h/o sexual promiscuity </li></ul><ul><li>FAMILY HISTORY: </li></ul><ul><li>- Not contributary </li></ul>
  8. 8. ON EXAMINATION <ul><li>Pt was </li></ul><ul><li>conscious </li></ul><ul><li>oriented </li></ul><ul><li>febrile </li></ul><ul><li>hydration fair </li></ul><ul><li>Pallor + </li></ul><ul><li>no icterus/cyanosis/clubbing </li></ul><ul><li>no SGLA </li></ul><ul><li>no PE </li></ul><ul><li>no skin rash </li></ul><ul><li>no sternal tenderness </li></ul>
  9. 9. <ul><li>VITALS : </li></ul><ul><li>pulse -92/min ,regular </li></ul><ul><li>BP-110/70 mm Hg </li></ul><ul><li>CVS: </li></ul><ul><li>S1S2+ </li></ul><ul><li>no murmur </li></ul><ul><li>RS: </li></ul><ul><li>NVBS+ </li></ul><ul><li>no added sounds </li></ul>
  10. 10. <ul><li>P/A : </li></ul><ul><li>soft </li></ul><ul><li>splenomegaly+, 5cm below LCM </li></ul><ul><li>firm, tender </li></ul><ul><li>no free fluid </li></ul><ul><li>BS+ </li></ul><ul><li>CNS : clinically normal </li></ul>
  11. 11. PROBLEMS <ul><li>fever , 1 month </li></ul><ul><li>loss of wt./loss of appetite </li></ul><ul><li>anaemia </li></ul><ul><li>splenomegaly </li></ul>
  12. 12. POSSIBILITIES <ul><li>-- chronic malaria </li></ul><ul><li>-- hematological disorder </li></ul><ul><li>-- immunocompromised state </li></ul>
  13. 13. WORK UP <ul><li>urine routine – alb-nil </li></ul><ul><li>sug -nil </li></ul><ul><li>dep-2-3 pus cells/hpf </li></ul><ul><li>urine c&s – no growth </li></ul><ul><li>Bleeding time-2 min </li></ul><ul><li>clotting time-4 min </li></ul><ul><li>PT-14 sec </li></ul><ul><li>aPTT-34sec </li></ul><ul><li>INR-1.2 </li></ul>
  14. 14. CBC 14/12/10 28/12/10 7/1/11 TC 4,200 3,100 2,200 DC P64/L35/E1 P66/L33/E1 P56/L34/E10 RBC count 3 million/cumm 2.6 million/cumm 1.8 million/cumm Hb 9.4gm% 8.7gm% 7.4gm% ESR 20/38 28/56 80 Platelet count 2.4 lakh/cumm 1.8lakh/cumm 1.3lakh/cumm
  15. 15. PERIPHERAL SMEAR 23/12/10 2/1/11 Normocytic ,normo chromic anaemia Platelets adequate Shift to left,no blasts Normocytic,hypochromic RBC s Platelets adequate Shift to left No blasts
  16. 16. <ul><li>LFT : </li></ul><ul><li>T.bilirubin-1.14mg/dl </li></ul><ul><li>direct bilrubin-0.56mg/dl </li></ul><ul><li>SGOT-35.7 </li></ul><ul><li>SGPT-32.9 </li></ul><ul><li>Alkaline phosphatase-181 </li></ul><ul><li>RFT: </li></ul><ul><li>Blood sugar-124mg/dl </li></ul><ul><li>blood urea-15mg/dl </li></ul><ul><li>s.creatinine-0.7m/dl </li></ul>
  17. 17. CHEST X RAY
  18. 18. FEVER PROFILE <ul><li>MP QBC- negative </li></ul><ul><li>Blood widal-negative </li></ul><ul><li>Dengue serology- negative </li></ul><ul><li>MSAT-1+ </li></ul><ul><li>HIV elisa-non reactive </li></ul><ul><li>VDRL-negative </li></ul><ul><li>HBsAG-negative </li></ul><ul><li>Anti HCV-negative </li></ul><ul><li>Blood c&s- no growth </li></ul>
  19. 19. <ul><li>ECG- WNL </li></ul><ul><li>ECHO- no RWMA </li></ul><ul><li>- normal LV systolic function </li></ul><ul><li>- no vegetations </li></ul>
  20. 20. USG ABDOMEN <ul><li>---- splenomegaly 19.6 cms </li></ul><ul><li>multiple hypo echoeic ill defined lesions </li></ul><ul><li>of varying sizes throughout the spleen , no </li></ul><ul><li>significant calcification </li></ul><ul><li>---- liver normal sized </li></ul><ul><li>normal echo texture,no focal abnormalities </li></ul><ul><li>---- multiple small peripancreatic , portal ,hilar nodes , largest node-11 × 7mm </li></ul>
  21. 21. CECT ABDOMEN
  22. 23. DIFFERENTIAL DIAGNOSIS <ul><li>INFECTION/INFLAMMATION: </li></ul><ul><li>- pyogenic abscess,fungal abscess,granulomatous infection ,hydatid cysts </li></ul><ul><li>CYSTIC NEOPLASM: </li></ul><ul><li>- lymphangiomatosis,lymphomas,cavernous </li></ul><ul><li>hemangioma </li></ul><ul><li>NECROTIC METASTSIS: </li></ul><ul><li>- malignant melanoma,breast,lung ,ovary </li></ul><ul><li>SARCOIDOSIS: </li></ul>
  23. 24. BONE MARROW STUDY <ul><li>---- Normal marrow precursors, no </li></ul><ul><li>immature cells, </li></ul><ul><li>myeloid: erythroid ratio of 5:1 </li></ul>
  24. 25. <ul><li>sputum AFB- negative </li></ul><ul><li>Mantoux- negative. </li></ul><ul><li>S. calcium – 9 mg/dl </li></ul><ul><li>24 hr urine calcium- 110mg </li></ul><ul><li>( Normal range 100-300mg) </li></ul><ul><li>S.ACE levels- 34u/l ( Normal range 10-60 u/l) </li></ul>
  25. 26. <ul><li>---IgM antibody to brucella – 1:10 </li></ul><ul><li>(normal > 1:320) </li></ul>
  26. 27. <ul><li>what next ? </li></ul>
  27. 28. USG GUIDED FNAC <ul><li>---- smear showed clusters of epitheliod histiocytes,admixed with mature and reactive lymphocytes , with caseating zones in the background </li></ul><ul><li>!? Granulomatous lesion, with caseating zones </li></ul>
  28. 29. PROBLEMS <ul><li>fever -2 months. </li></ul><ul><li>significant loss of weight/appetite. </li></ul><ul><li>anaemia. </li></ul><ul><li>splenomegaly. </li></ul><ul><li>Rapidly progressing Bi-cytopenia </li></ul><ul><li>FNAC evidence of granulomatous lesion with caseating zones. </li></ul>
  29. 30. <ul><li>? </li></ul>
  30. 31. FINAL DIAGNOSIS <ul><li>“ SPLENIC TUBERCULOSIS” </li></ul>
  31. 32. <ul><li>--- CAT -1 ATT was started for the patient , fever subsided completely within 2 weeks </li></ul>
  32. 33. FOLLOW UP <ul><li>--- patient turned up after 2 months </li></ul><ul><li>improved GC </li></ul><ul><li>improved body wt </li></ul><ul><li>CBC: TC-6500cells/cumm </li></ul><ul><li>DC-66/32/2 </li></ul><ul><li>RBC count -3 million/cumm </li></ul><ul><li>Hb-9.6 gm/dl </li></ul><ul><li>ESR- 10/22 </li></ul><ul><li>Platelet count -1.5 lakh/cumm </li></ul>
  33. 34. <ul><li>Rpt. USG abdomen- splenomegaly decreased </li></ul><ul><li>(15cms.) </li></ul><ul><li>- hypoechoeic lesions </li></ul><ul><li>disappeared significantly </li></ul><ul><li>- peripancreatic ,portal </li></ul><ul><li>nodes not visualised. </li></ul>
  34. 35. FEW CASE REPORTS <ul><li>Sato T, Mori M, Inamatsu T, Watanabe J, Takahashi T, Esaki Y. </li></ul><ul><li>Department of Medicine, Tokyo Metropolitan Geriatric Hospital. </li></ul><ul><li>A case of splenic tuberculosis is reported . The patient was a 79-year-old man who was admitted to the Tokyo Metropolitan Geriatric Hospital because of high fever and loss of body weight. Several finger-tip sized superficial lymph nodes were palpable in bilateral inguinal regions. The computed tomogram of the abdomen showed moderate enlargement of the spleen with multiple low density areas and several swollen lymph nodes in the para-aortic region. Although a lymph node of the inguinal region was resected for the pathologic examination, it showed no specific changes. In order to obtain a final diagnosis, laparotomy was performed. The spleen was markedly enlarged and nodular in appearance. No abnormal findings were observed in the other abdominal organs. Splenectomy was carried out. Numerous yellowish nodules, varying from 0.1 to 5 cm in diameter, were observed on the cut surface of the resected spleen (20 x 20 x 8 cm, 700 g). Recently, isolated tuberculosis of the spleen has become very rare. Since 1965, only six cases in five reports can be found in the English, French and German literature. The present case is considered to be one such very rare cases of tuberculosis. Although splenic tuberculosis is rare at the present time, splenic tuberculosis should be included in the differential diagnosis of fever of unknown origin with splenomegaly. </li></ul><ul><li>PMID: 1614011 [PubMed - indexed for MEDLINE]Free Article </li></ul>
  35. 36. <ul><li>Isolated Tuberculosis of the Spleen : A Rare Clinical Entity </li></ul><ul><li>Citation: S. Dalal, Nityasha, R. S. Dahiya & Prashant : Isolated Tuberculosis of the Spleen: A Rare Clinical Entity . The Internet Journal of Surgery. 2008 Volume 16 Number 1 </li></ul><ul><li>Adil et al. reported a series of 12 immunocompetent individuals with splenic tuberculosis but all of them had one or more extra site of tuberculous involvement along with the spleen. 5 Generally, these cases present with mild pyrexia and chronic weight loss and are diagnosed during investigational work up for PUO. Rarely, splenic tuberculosis has also been diagnosed incidentally during laparotomy that was carried out for abdominal trauma. </li></ul><ul><li>1. Ho PL, Chim CS, Yuen KY. Isolated splenic tuberculosis presenting with pyrexia of unknown origin. Scand J Infect Dis 2000; 32: 700-01. (s) </li></ul><ul><li>2. Sambrook J, Frisch EF, Maniatis T. Molecular Cloning. A laboratory manual. Vol. II, 2nd edition. Cold Spring Laboratory Press, 1989. (s) </li></ul><ul><li>3. Eisenach KD, Crawford JT, Bates JH. Repetitive DNA sequences as probes for mycobacterium tuberculosis. Journal of Clinical Microbiology 1988; 26: 2240-45. (s) </li></ul>
  36. 37. <ul><li>Indian J Med Res 125, May 2007, pp 669-678 </li></ul><ul><li>Radiological manifestations of splenic tuberculosis: A 23-patient </li></ul><ul><li>case series from India </li></ul><ul><li>S.K. Sharma, Duncan Smith-Rohrberg+, Mohammad Tahir, Alladi Mohan++ & Ashu Seith* </li></ul><ul><li>Departments of Medicine, *Radiodiagnosis, All India Institute of Medical Sciences, New Delhi,+AIDS Program, </li></ul><ul><li>Department of Internal Medicine, Yale University School of Medicine, New Haven & ++Sri Venkateswara </li></ul><ul><li>Institute of Medical Sciences, Tirupati, India </li></ul>
  37. 38. SPLENIC TUBERCULOSIS <ul><li>TB of spleen can occur </li></ul><ul><li>1) disseminated TB </li></ul><ul><li>2) isolated splenic TB </li></ul><ul><li>Not uncommon in HIV setting. </li></ul><ul><li>Very rare in immuno-competant individuals. </li></ul><ul><li>In disseminated TB </li></ul><ul><li>1)lung-100% </li></ul><ul><li>2)liver -80% </li></ul><ul><li>3)lymphnode -55% </li></ul><ul><li>4)bone marrow-40% </li></ul><ul><li>5)spleen-30% </li></ul>
  38. 39. Clinical presentations <ul><li>pyrexia of unknown origin </li></ul><ul><li>chronic LUQ pain </li></ul><ul><li>wt. loss </li></ul><ul><li>unexplained anaemia </li></ul><ul><li>mass abdomen </li></ul><ul><li>splenomegaly –hypersplenism can mimic hematological disorders. </li></ul>
  39. 40. management <ul><li>search for evidence of TB else where </li></ul><ul><li>USG/CECT abdomen –1)hypoechoiec lesions </li></ul><ul><li>diffuse- in TB </li></ul><ul><li>coalescent –in sarcoidosis </li></ul><ul><li>2)large isolated tuberculoma </li></ul><ul><li>Histopathological examination </li></ul><ul><li>Microbiological examination ( AFB demonstration, </li></ul><ul><li>AFB culture) </li></ul>
  40. 41. <ul><li>ATT – short course chemotherapy </li></ul><ul><li>- extended regimen for 1 year </li></ul><ul><li>Splenectomy </li></ul>
  41. 42. CARRY HOME POINTS <ul><li>Isolated splenic TB is very rare in immuno-competent individuals </li></ul><ul><li>Still it should be considered in D/D of PUO regardless of HIV status---in Indian scenario </li></ul><ul><li>CECT is a very good screening tool </li></ul><ul><li>Tissue diagnosis forms the main stay of diagnosis </li></ul><ul><li>ATT +/- splenectomy --- treatment options </li></ul>
  42. 43. THANK YOU

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