A 22-year-old nonsmoker, nonalcoholic male from a middle-class family in the midwestern part of Nepal was referred to our tertiary center with intermittent fever, pain in the left lower chest, occasional nausea and vomiting, anorexia, and weight loss of three-week duration. Symptoms did not improve with two weeks of broad-spectrum oral and then parenteral antibiotics at a local hospital. Fever was associated with chills and rigors. Left lower chest pain was continuous with radiation to the left shoulder. There was no associated cough, shortness of breath, altered bowel or bladder habits, jaundice, headache, vomiting, joint pain, or any skin nodules. There was no history of drug abuse or sexual promiscuity. There was no history of diabetes mellitus and no past or family history of TB.
On examination, the patient's body temperature was 102 F, pulse was 100 beats per minute, and respiratory rate was 16 breaths per minute and regular. Chest examination showed tenderness in the left infra-axillary region and normal bilateral vesicular breath sounds without any additional sounds. Cardiovascular examination revealed normal heart sounds without murmur. Abdominal examination showed a soft, tender left upper quadrant with Traube's space dullness; however, the spleen and liver were not palpable. Complete blood count, liver and renal function tests, posteroanterior chest X-ray, and echocardiography were normal. Erythrocyte sedimentation rate (ESR) using Wintrobe's method was elevated at 58 mm per hour. Purified protein derivative (PPD) was 12 mm. Sputum samples on three consecutive days were negative for acid-fast bacillus (AFB). Spot serological tests for human immunodeficiency virus, hepatitis B, and hepatitis C were nonreactive. Three consecutive bacterial blood cultures and a urine culture showed no growth. Serologic tests for malaria, leptospirosis, brucellosis, and leishmaniasis were negative. Ultrasound of the abdomen (Figure 1) revealed a 5.3 x 4.0 x 3.5 cm hypoechoic lesion at the lower pole of the spleen that was in communication with a similar lesion of an approximately 40 ml collection at the perisplenic area. Likewise, a 3.9 x 3.0 x 2.8 cm collection at the superior pole of the spleen was in communication with a similar collection at the perisplenic area. Contrast-enhanced computed tomography of the abdomen (Figure 2) showed two perisplenic hypodense collections of 6.9 x 5.1 x 3.2 cm at the inferior pole and 5.2 x 4.0 x 3.0 cm at the superior pole of the spleen having connections with similar splenic parenchymal collections, suggestive of multiple splenic abscesses with perisplenic extensions. The patient did not improve with three weeks of empiric parenteral broad-spectrum antibiotics.
Diagnostic and therapeutic ultrasound-guided aspiration removed approximately 30 ml of pus which was sent for microbiological and molecular examination for MTB. The pus was negative for AFB staining; however, PCR for MTB was positive. Gram's stain revealed no bacteria, and routine 72-hour bacterial culture showed no microorganism growth.
Diagnosis of primary splenic tuberculosis was made, and as per directly observed treatment, short course (DOTS), ATT category I was initiated for 6 months. One week after starting ATT, the patient improved clinically with fever resolution and an increase in appetite. The patient was then discharged on ATT. On follow-up, the patient had clinically improved and gained weight. Serial ultrasounds of the abdomen showed a gradual decline in the abscess sizes. Upon completion of six months of ATT, the patient was clinically asymptomatic and had normal ESR, and ultrasound of the abdomen (Figure 3) showed normal spleen.