Splenic tuberculosis and HIV-1 infection

Abstract

Despite notable advances in diagnosis and treatment, tuberculosis continues to be a major health hazard. Incidence of HIV-1 infection is reaching pandemic proportions, and tuberculosis has resurged even in more-developed countries.1Chandra S Srivastava DN Gandhi D Splenic tuberculosis: an unusual sonographic presentation.Int J Clin Pract. 1999; 53: 318-319PubMed Google Scholar We saw a man aged 23 years who presented with acute abdominal pain of 6 h duration. He denied a history of trauma. On clinical examination he was pale and hypotensive. He had abdominal tenderness and generalised abdominal distension. Paracentesis revealed free-flowing blood. An emergency exploratory laparotomy revealed a haemoperitoneum. The spleen was enlarged and there was a large laceration on the posterolateral surface. Histopathology revealed multiple necrotic masses with caseating granulomas on microscopy. Acid-fast bacilli were seen. HIV-1 ELISA was positive. Postoperatively, we administered multidrug tuberculosis chemotherapy for 9 months. At 1 year after surgery the patient was symptom free. Tuberculosis is a systemic disease with varied manifestations. Extra-pulmonary tuberculosis accounts for almost 15% of all cases of tuberculosis. The most common site of extra-pulmonary tuberculosis is the abdomen, where the intestines are generally involved, mainly in the ileocaecal region and the lymph nodes. Splenic tuberculosis is very rare. This form is normally seen as a part of miliary tuberculosis and is rarely the isolated presenting feature. Incidence of tuberculosis has risen, mainly because of increased incidence of HIV-1 infection.1Chandra S Srivastava DN Gandhi D Splenic tuberculosis: an unusual sonographic presentation.Int J Clin Pract. 1999; 53: 318-319PubMed Google Scholar Presenting symptoms are usually vague and include fever, weight loss, and nonspecific abdominal pain. The patient may or may not have a history of pulmonary tuberculosis. For disseminated miliary tuberculosis, clinical findings include generalised lymphadenopathy and pulmonary tuberculosis on respiratory examination. Abdominal examination may reveal hepato-splenomegaly, lymphadenopathy, and ascites. Splenic rupture is frequently caused by trauma. Spontaneous splenic rupture by itself is unusual, but has been described in diseased spleens such as in chronic malaria and infectious mononucleosis. Splenic tuberculosis presenting with rupture is extremely rare—only two cases have been reported. The first was a patient with sarcoidosis who had been treated with steroids and who developed disseminated tuberculosis. The disease was complicated by splenic rupture and a reactive haemophagocytic syndrome; the patient subsequently died.2Lam KY Ng WF Chan AC Miliary tuberculosis with splenic rupture: a fatal case with hemophagocytic syndrome and possible association with long standing sarcoidosis.Pathology. 1994; 26: 493-496Summary Full Text PDF PubMed Scopus (20) Google Scholar The other patient presented with recurrent gastric haemorrhage due to a ruptured splenic haemangioma and associated splenic tuberculosis.3Rao RC Ghose R Sawhney S Berry M Hemangioma of spleen with spontaneous, extra-peritoneal rupture, with associated splenic tuberculosis—an unusual presentation.Australas Radiol. 1993; 37: 100-101Crossref PubMed Scopus (10) Google Scholar Splenic rupture in most cases necessitates laparotomy with splenectomy. Conservative surgery is not possible in diseased spleens because of the friable tissues and the risk of recurrence. Furthermore, splenectomy generally provides the diagnosis in a diseased spleen.