A 60-year-old male patient visited our hospital with vomiting, pain in abdomen and distension of abdomen since one month. He also gives history of weight loss, loss of appetite, low grade fever. He was non-smoker and non-alcoholic. He had no significant past history of pulmonary tuberculosis or any contact with patient of TB or neither had HIV infection. He was not screened for diabetes mellitus and hypertension. On examination he was afebrile, regular pulse at 84/min. His blood pressure was 120/70 mmhg. He was anicteric and there was no lymphadenopathy. On abdominal examination shifting dullness and fluid thrill suggestive of free fluid in the peritoneal cavity was present. Spleen was not palpable. Investigation revealed haemoglobin of 9 gram percent, fasting blood sugar was 98 mg/dl, erythrocyte sedimentation rate (ESR) of 90 mm/1st hour. His tuberculin test was positive (18 mm). The HIV serologic test was negative. Other Blood biochemical profile like liver function test and kidney function test were within normal limits. The chest X-ray revealed no abnormalities. Abdominal ultrasonography revealed ascites with multiple ill defined areas of hypoechogenesity in spleen. The axial contrast enhanced Computerised Tomography showed irregular hypo dense peripherally enhancing lesions in spleen, and fluid in anterior perihepatic space suggestive of splenic abscess [Figure 1]. There was no bowel thickening, no septa and no lymph node enlargement. The computed tomography (CT) guided fine needle aspiration biopsy from hypo echogenic area of spleen was performed. The cytomorphology showed granulomas with area of caseation in the centre surrounded by variable number of langhans giant cells and epitheloid cells favouring diagnosis of tuberculosis [Figure 2]. Culture and polymerase chain reaction based confirmation could not be contemplated due to inadequacy of sample. Ascitic fluid examination revealed total white cell count of 450 with lymphocyte 85%, protein 4.6 mg/dl, glucose 60 mg/dl, LDH 442 u/l, cholesterol 43 mg/dl. Serum ascitic albumin gradient was 0.8 suggestive of exudative fluid. Tuberculosis is one of the common causes of exudative fluid in this part of the world. Microscopy was requested for malignant cells and mycobacterium which was negative.
The final diagnosis was multiple splenic tubercular abscesses with tubercular ascites. We put him on DOTS category two anti tubercular therapy. He was doing well on follow up which was regular for three month.