A 55-year-old male presented with a gradually increasing mass on the left lateral lower chest and upper abdomen over a period of one year. He had no other medical problems and no history of contact with a tuberculous patient. On examination, a lobulated subcutaneous mass measuring about 7 cm in diameter, soft to cystic in consistency, immobile and attached to the skin which was tense and slightly red, tender but not warm, not pulsating, and with no bruit was found on the left lower chest and upper abdomen laterally. The spleen was enlarged 8 cm below the costal margin. Other systems were normal.
Chest X-rays showed a calcified lesion near the hilum of the right lung suggestive of an old pulmonary tuberculosis. Abdominal radiographs showed calcified lesions in the left upper quadrant (Figure 1). Ultrasound of the abdomen indicated an enlarged spleen with areas of calcification. CT scan of the abdomen revealed a splenic abscess communicating with another subcutaneous abscess through the lower chest wall (Figure 2). Based on these data, a complicated tuberculous splenic abscess was the most probable diagnosis.
Under general anesthesia, the subcutaneous abscess was incised and drained, and splenectomy was performed simultaneously. The spleen was found to be enlarged, fibrotic, and adherent to the lower chest wall. There was an abscess cavity within the spleen communicating with the subcutaneous abscess through a small tract in the lower chest wall below the insertion of the diaphragm. The abscesses contained thick pus and necrotic material. Histopathology of the spleen revealed the characteristic tuberculoid granuloma with epithelioid cells, Langhans' multinucleated giant cells, and caseation necrosis (Figure 3). Acid fast bacilli staining, tuberculous and bacterial cultures were all negative.
The patient was started on Isoniazid (INH) 300 mg OD, Rifampin 600 mg OD, Ethambutol 600 mg OD and Pyrazinamide 500 mg OD for 5 weeks, then maintained on the former two drugs. The patient's condition improved on anti-tuberculous medications and showed good clinical progress at one-year follow-up.