A Rare Presentation of Tuberculosis as a Splenic Abscess

Abstract

Aims: Splenic tubercular abscess is a very unusual clinical presentation in an immunocompetent host. This rare clinical condition which can occur in two forms. The first form where splenic involvement is seen as a part of miliary Tuberculosis especially in immune-compromised individuals. The second form is the primary involvement of the spleen which is extremely rare.  Presentation of the Case: We encountered a case of a middle aged immunocompetent male who presented with vague pain in the left hypochondrium for 3 months duration and fever for 3 days. On clinical examination he had tenderness over the left hypochondrium. On admission he had lymphocytosis with elevated ESR. His Mantoux test was positive. CT scan abdomen revealed multiple hypodensities in spleen,the largest measuring 12x11mm and suspected to be granulomas of Tuberculosis. Laparoscopic splenectomy was done. Histopathological examination showed large areas of caseation surrounded by multiple granulomas of epithelioid and Langerhans type of giant cells suggestive of tuberculosis. No primary focus of tuberculosis was detected in lungs or other organs. Anti-tubercular therapy was started and the patient became afebrile and his general condition improved. Discussion: Splenic involvement was generally thought to be seen only in immunocompromised stages. However, there are sporadic case reports of splenic Tuberculosis in immunocompetent patients such as ours.Where splenic involvement is seen as a part of miliary Tuberculosis especially in immune-compromised individuals, which is less rare, the treatment includes classic antituberculous treatment, and surgical intervention is required as a rare exception . The second form, which is the primary involvement of the spleen, is extremely rare. Early splenectomy followed by oral antituberculous drugs may be considered the more appropriate approach for this entity. Conclusion: Tuberculosis may have protean manifestations and becomes  difficult to diagnose when it presents in an uncommon extrapulmonary site. Hence, although primary splenic tuberculosis  is extremely rare , it should be also considered  among  the differential diagnoses  of abscesses in the spleen in the regions with high prevalence of Tuberculosis.