A 53-year-old farmer known to have diabetes mellitus with well-controlled blood sugars presented with intermittent episodes of high grade fever for more than a year. He had occasional dull aching pain in the left subcostal region. There was no history of reduction of weight or appetite. He never consumed ethanol. In the beginning, he received a course of antitubercular drugs for 6 months duration for a diagnosis of extrapulmonary TB in spleen, despite which his symptoms persisted.
On examination, he had normal vital signs and insignificant axillary lymphadenopathy. He had mild hepatosplenomegaly and a dull Traube's space. Rest of his systemic examination was unremarkable. The differentials considered for hypoechoic lesions in the spleen with pyrexia of unknown origin were extrapulmonary TB, sarcoidosis, infective endocarditis, splenic marginal zone lymphoma, B. pseudomallei abscess, histoplasmosis, and hematological malignancy.
His routine blood investigations were normal except for an elevated C-reactive protein (CRP) of 9.8 mg/L (ref range: <6 mg/L) and erythrocyte sedimentation rate of 60 mm/h (ref range: 3-10 mm/h). At admission, his glycated hemoglobin was 6.7%. Sonography of the abdomen revealed multiple hypoechoic lesions in the spleen with peripheral calcification which was suggestive of multiple granulomas. These findings were confirmed on computed tomography scan of the abdomen [Figures 1-3]. Serial blood cultures showed no growth. Blood-borne virus screen, angiotensin-converting enzyme levels, chest X-ray, echocardiography, and bone marrow examination were normal. Ultrasound-guided fine-needle aspiration cytology of the splenic lesion was negative for X-pert TB polymerase chain reaction and for malignant cells. Axillary lymph node biopsy did not yield any positive results. Diagnostic splenectomy was being considered when bacterial culture from the splenic aspirate grew B. pseudomellei and he was initiated on intravenous ceftazidime.
Three days later, he was noted to have icterus. Liver function tests revealed indirect hyperbilirubinemia (total bilirubin 2.2 mg/dL [ref range: 0.5-1 mg/dL]) and direct bilirubin 1.7 mg/dL with normal liver enzymes. His platelet counts dropped to <15,000/cumm3. He had mucosal bleeding and melaena necessitating platelet transfusions. The differentials considered for his thrombocytopenia were DIC, TTP, and drug-induced thrombocytopenia. However, his fibrinogen level was normal, schistocytes were absent, and coagulation parameters were normal. It was found that he was on diclofenac for pain relief after lymph node biopsy and it was stopped. Thrombocytopenia persisted despite stopping diclofenac, and ceftazidime-induced immune thrombocytopenia was considered. His antibiotic therapy was changed to meropenem along with 4 days of dexamethasone. He received 4 weeks of intravenous antibiotics and was discharged with an advice to continue co-trimoxazole and doxycycline for a period of 3 months. His platelet counts improved, and he was well at the time of discharge. During the follow-up visits, his CRP showed declining trend, and he was found to be well.