A 7-year-old Chinese girl presented to our department with a 3-week history of low-grade fever and cough. Her previous history was unremarkable. Physical examination revealed a soft abdomen with a tender liver edge 3 cm below the right costal margin and a palpable spleen tip; the chest was found to be normal. Routine laboratory tests were normal except for hemoglobin 9.9 gr/dL (nv 11.5-14.5) and erythrocyte sedimentation rate (ESR) of 79 mm/h (nv < 38). Tuberculin skin test was positive with 20 mm induration. Quantiferon-TB Gold test was 59 IU/mL (nv < 0.34). HIV test was negative. Chest X-ray showed mild thickening along the right major fissure and bilateral hilar enlargement. Abdominal ultrasound (US) performed using a 3.5 mHz convex transducer (Acuson Sequoia 512, Siemens, Mountain View, CA, USA) revealed mild hepatomegaly, multiple hypoechoic nodules up to 13 mm in diameter scattered throughout the liver and spleen (Fig. 1); slight wall thickening of the last ileal loop and ascending colon, and multiple enlarged mesenteric lymph nodes were also shown. Multidetector computed tomography (CT) of the abdomen was performed using 16-slice CT scan (LightSpeed, GE Healthcare, Milwaukee, WI, USA) with 5-mm slice thickness (reconstructed 2.5 mm) and low dose technique (80 kv, 50-90 mAs) after i.v. contrast medium administration. CT revealed multiple rounded, low-density lesions in the liver and spleen, ranging in size from 2 to 18 mm (Fig. 2); peripancreatic, periportal, para-aortic, and paracaval lymph nodes up to 15 mm in diameter with no calcification, and diffuse small bowel wall thickening were also shown. CT of the chest demonstrated small opacities in the right lower lobe and multiple enlarged lymph nodes in the hilar, paraesophageal, and paratracheal regions (Fig. 3). Direct smear microscopy for acid-fast bacilli in the sputum and gastric lavage was negative, but the culture for Mycobacterium tuberculosis was positive. Colonoscopy showed a nodular, ulcerated mass that partially obstructed the cecum. Intestinal biopsy and image-guided needle biopsy of the liver revealed granulomatous tissue with caseous necrosis. Both direct smear microscopy for acid-fast bacilli and culture for Mycobacterium tuberculosis of intestinal and liver biopsy specimens were negative.    
Diagnosis of macronodular hepatosplenic TB with concomitant intestinal and lung involvement was made, and a three-drug anti-TB therapy consisting of isoniazid, rifampicin, and pyrazinamide was planned. After 9-month therapy, there was a marked improvement in the general condition, and the liver and spleen were no longer palpable. Abdominal US revealed reduction in size and peripheral calcification of the hepatosplenic lesions (Fig. 4); abdominal lymph nodal groups were normal.