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HISTOPATHOLOGY SECTION - CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 1  |  Page : 74-75
Acid-fast bacilli positive isolated tubercular splenic abscess in a HIV-negative patient


1 Department of Pathology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
2 Department of Surgery, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

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   Abstract 

Isolated splenic tubercular abscess in a HIV-negative patient is an exceedingly rare clinical condition. It is even more rare to demonstrate acid-fast bacilli positivity on Ziehl-Neelson stains in such cases. We hereby present one such case.

Keywords: Acid-fast bacilli positive, HIV negative, isolated splenic abscess

How to cite this article:
Jain M, Singh S, Thomas S, Jain D. Acid-fast bacilli positive isolated tubercular splenic abscess in a HIV-negative patient. Indian J Pathol Microbiol 2008;51:74-5

How to cite this URL:
Jain M, Singh S, Thomas S, Jain D. Acid-fast bacilli positive isolated tubercular splenic abscess in a HIV-negative patient. Indian J Pathol Microbiol [serial online] 2008 [cited 2020 Oct 25];51:74-5. Available from: https://www.ijpmonline.org/text.asp?2008/51/1/74/40406



   Introduction Top


Splenic abscess is a rare clinical entity with an incidence of 0.14-0.7% in autopsy-based studies. [1],[2] Its rarity is also evidenced by its absence from a review of 540 intraabdominal abscesses. [3] Tuberculosis is a rare cause of splenic abscess in immunocompetent patients. [4],[5],[6],[7]


   Case History Top


A 28-year-old married female, presented to the outpatient department with a 6-month history of low-grade fever off and on, dull pain in the left upper abdomen, and anorexia; and weight loss. There was no history of cough, hemoptysis, or lymphadenopathy. There was a history of contact with tuberculosis - her husband was undergoing treatment for pulmonary tuberculosis. She had taken several antibiotic courses with a suspected diagnosis of enteric fever with only partial response.

On examination, she was thin built and moderately nourished, and had no fever, tachycardia or significant generalized lymphadenopathy. Examination of the cardiovascular and respiratory systems was normal. Abdominal examination revealed a firm tender splenomegaly 5 cm below the left costal margin. There was no hepatomegaly, ascites, or any other mass palpable in the abdomen.

Laboratory investigations revealed Hb 9.5 g%, TLC 14 000/mm 3 , P 66 L 32 E 1 M 1 , ESR 55 mm in the first hour, and no parasites in the peripheral smear. Liver and kidney functions as well as chest X-ray were normal. Serum Widal and serial blood cultures were negative, and the tuberculin test was nonreactive. Ultrasound of the abdomen revealed multiple hypoechoic areas in a moderately enlarged spleen, the largest being 2 x 2.1 cm 2 suggestive of multiple abscesses. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed splenomegaly with multiple well-defined round nonenhancing hypodense lesions with imperceptible wall, rim enhancement, and one calcific focus in the spleen. There was no bowel thickening, lymph node enlargement, or free fluid in the abdomen. Barium studies showed normal bowel and ileo-caecal region. Enzyme-linked immunosorbent assay (ELISA) for HIV, and serology for Echinococcus granulosus were negative. ELISA for Mycobacterium tuberculosis -IgM was borderline positive though IgG was negative.

With a clinical diagnosis of splenic abscess, the patient was treated empirically with broad-spectrum antibiotics for 2 weeks. Persistent low-grade fever, malaise, tender splenomegaly, and nonresolution of the lesions on repeat ultrasound, prompted the decision for splenectomy, both for definite diagnosis and treatment. During surgery, the spleen was densely adhered to surrounding structures. Postoperatively the patient was started on chemotherapy for tuberculosis; she showed significant improvement 3 weeks after surgery.

Pathological findings

The spleen, on cut section, showed multiple 'cheesy' abscesses [Figure - 1]. Histopathological examination revealed wide areas of caseous necrosis with very few epitheloid cells at the periphery. No well-defined granulomas were seen. Thick bands of fibrous tissue surrounded the abscesses. Ziehl-Neelson (ZN) stain for acid-fast bacilli (AFB) was positive [Figure - 2].


   Discussion Top


Because of the rareness of this entity, there are very few reviews, the most extensive being one published by Alonso Cohen and associates [8] who reviewed 227 cases published in the world literature till 1988. The most accepted classification is that of Chun and colleagues [9] who divide splenic abscesses according to the predisposing causes: primary pyogenic abscess, after splenic trauma, in patients with hemoglobinopathies, and due to contagious diseases affecting the spleen.

The presence of a septic focus in some part of the organ is the most frequent cause of splenic abscess. Nearly 69% of the patients Alonso Cohen and colleagues reviewed had an infectious etiology; [8] the commonest causes being typhoid fever, malaria, and amoebic dysentery in the preantibiotic era, and bacterial endocarditis and urinary infection today. [9],[10],[11]

There has also been an increase in the incidence of specific abscesses in patients treated with immunosuppressive drugs as well as in neutropenic patients, fungi being the most frequent offenders. [10],[12]

Splenic abscesses appear mostly in males (57%). In most of the cases, symptoms are insidious and nonspecific. Fever is the most frequent symptom (92.5%), followed by vague abdominal pain (57.7%). Pain in the left hypochondrium appears only in 39.2% of cases. [8] The best diagnostic methods are CT scan and sonography. Sonographically, splenic abscesses appear as lesions of mixed echogenicity and are generally anechonic with a surrounding hyperechoic zone. [8]

The most frequent complication of splenic abscess is its rupture into the peritoneal cavity causing acute peritonitis. [1] An untreated splenic abscess can also produce repeated bacteremia, which may end in septic shock. Nontreated splenic abscesses have a high mortality; but sometimes, they are overlooked and they develop into a chronic state. [9] Treatment of choice is splenectomy and drainage with postoperative antibiotic therapy. [1]

Opportunistic infections are common in patients with AIDS. There is an increasing incidence of tuberculosis, especially extra pulmonary tuberculosis in these patients. Splenic abscess due to tuberculosis is rare, mostly diagnosed in immunocompomised hosts or as part of miliary tuberculosis. Isolated tubercular splenic abscess in an HIV-negative patient is rarer still, having been reported only in few instances in literature. [4],[5],[6],[7]

There are very few reported cases of ZN stain positive isolated tubercular splenic abscesses. [13] The case being reported is one such very rare example where diagnosis was confirmed by demonstrating AFB on ZN stain. Most cases have been diagnosed using culture techniques or clinical improvement seen after start of empirical antitubercular therapy.

 
   References Top

1.Lahorne TW, Zuidema GD. Splenic abscess. Surgery 1976;79:686-9.  Back to cited text no. 1    
2.Gadacz TR. Splenic abscess. World J Surg 1985;9:410-5.  Back to cited text no. 2  [PUBMED]  
3.Altemeier WA, Culbertson WR, Fullen WD, Shook CD. Intraabdominal abscesses. Am J Surg 1973;125:70-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Gotor MA, Mur M, Guerrero L, Aspiroz C, Romero D, Gimeno E. Tuberculous splenic abscess in an immunocompetent patient. Gastroenterol Hepatol 1995;18:15-17.  Back to cited text no. 4  [PUBMED]  
5.Sharma S, Dey AB, Agarwal N, Nagarkar KM, Gujral S. Tuberculosis: a rare cause of splenic abscess. J Assoc Physicians India 1999;47:740-1.  Back to cited text no. 5  [PUBMED]  
6.Bastounis E, Pikoulis E, Varelas P, Cirochristos D, Aessopos A. Tuberculoma of the spleen: a rare but important clinical entity. Am Surg 1999;65:131-2.  Back to cited text no. 6  [PUBMED]  
7.Neki NS, Batra KS, Sharma PK, Sidhu BS, Multani LS, Sharma N. Isolated tubercular splenic abscess. J Assoc Physicians India 2001;49:759-60.  Back to cited text no. 7    
8.Alonso Cohen MA, Galera MJ, Ruiz M, Puig La Calle J, Rius X, Artigas V. Splenic abscess. World J Surg 1990;14:513-7.  Back to cited text no. 8    
9.Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R, et al . Splenic abscess. Medicine 1980;59:50-65.  Back to cited text no. 9  [PUBMED]  
10.Nelken N, Ignatius J, Skinner M, Christensen N. Changing clinical spectrum of splenic abscess. Am J Surg 1987;154:27-34.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Simson JN. Solitary abscess of the spleen. Br J Surg 1980;67:106-10.  Back to cited text no. 11  [PUBMED]  
12.Helton WS, Carrico CJ, Zaveruha PA, Schaller R. Diagnosis and treatment of splenic fungal abscesses in the immune-suppressed patient. Arch Surg 1986;121:580-6.  Back to cited text no. 12  [PUBMED]  
13.Sato T, Mori M, Inamatsu T, Watanabe J, Takahashi T, Esaki Y. Isolated splenic tuberculosis. Nippon Ronen Iggakkai Zasshi 1992;29:305-11.  Back to cited text no. 13    

Top
Correspondence Address:
M Jain
Department of Pathology, Lady Hardinge Medical College and Associated Hospitals, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.40406

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    Figures

  [Figure - 1], [Figure - 2]

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    Abstract
    Introduction
    Case History
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