A 21-year-old female presented with left-sided chest pain and low grade fever for one month. The clinical examination and X-ray chest were suggestive of moderate pleural effusion. She underwent thoracocentesis and about one liters of straw colored fluid was drained. The fluid was exudate (protein 4 gm %), lymphocytes predominant (cells 6800/mm3, 90% lymphocytes) with adenosine deaminase (ADA) level of 120 units. Her routine investigations including blood count, fasting blood sugar, liver function tests, renal function tests, urine examination, etc., were normal but erythrocyte sedimentation rate (ESR) was 110 mm in the first hour. Mantoux test revealed an induration of 15 mm. She was HIV sero negative and ultrasound abdomen was normal. Pleural biopsy revealed features of tubercular granulomas. Pleural fluid culture by Bactec method revealed mycobacterium tuberculosis sensitive to first line antituberculosis drugs.
She was initiated on intermittent, directly observed, thrice weekly antituberculosis chemotherapy with isoniazid (600 mg), rifampicin (450 mg), and pyrazinamide (1,500 mg), under category III revised national tuberculosis control program of India. She responded with above treatment and became asymptomatic with regression of pleural effusion that disappeared completely after four weeks of therapy.
She remained asymptomatic till six weeks when she noticed dull aching pain abdomen at epigastrium and left hypochondrium. The pain gradually increased and did not subside with the addition of omeprazole and antacids. There was no associated vomiting and diarrhea. On examination, there was tenderness at left hypochondrium. Ultrasound abdomen this time revealed mild splenomegaly with multiple hypoechoic areas (the largest one measuring 19 x 15 x 10 mm3, at lower part) [Figure 1]. CT scan abdomen also confirmed enlarged spleen with multiple miliary size abscesses. There were no other intraabdominal abnormalities. Ultrasound-guided fine needle aspiration cytology (FNAC) of splenic lesion revealed the collection of inflammatory cells including epitheloid cells, lymphocytes, multinucleated giant cells with extensive caseous necrosis; but no acid-fast bacilli [Figure 2].
A possibility of paradoxical response to antituberculosis therapy was strongly considered. She was given a course of oral prednisolone starting at 40 mg/day that was rapidly tapered off in four weeks, while she was maintained on the same antituberculosis regimen. There was marked clinical response on steroid therapy and repeat ultrasound abdomen, following a course of systemic corticosteroid showed near complete resolution of the splenic lesions; which completely disappeared at the end of antituberculosis treatment that patient received for six months.