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Indian Journal of Medical Microbiology, Vol. 28, No. 2, April-June, 2010, pp. 172-173 Case Report Asymptomatic, isolated tubercular splenic abscess, in an immunocompetent person *U Udgaonkar, S Kulkarni, S Shah, S Bhave Departments of Microbiology (UU,SK,SS) and Obstetrics and Gyenaecology (SB), Bharati Vidyapeeth Medical College and Hospital, Sangli, Maharashtra - 416 414, India. Correspondence Address: *Department of Microbiology, Bharati Vidyapeeth Medical College and Hospital, Sangli, Maharashtra - 416 414, India, ushasubodh@yahoo.com Date of Submission: 06-May-2009 Code Number: mb10051 PMID: 20404470 DOI: 10.4103/0255-0857.62501 Abstract Tubercular splenic abscess in an immunocompetent person, especially when the patient is without any symptoms, is a rare clinical entity. We report a case of isolated tubercular splenic abscess in a 38-year-old asymptomatic healthy female and emphasize the importance of careful smear examination. The patient had come to the hospital for repair of vaginal vault prolapse. Her abdominal ultra sonography showed normal sized spleen with hypoechoic areas suggesting abscess. Fine needle aspiration of splenic lesion revealed tubercle bacilli on Ziehl Neelsen stain. The organisms also grew on culture. The splenic lesions cleared after six months of treatment with anti tubercular drugs at our Directly Observed Treatment centre under Revised National TB Control Programme. The patient was operated successfully for vault prolapse one year later.Keywords: Asymptomatic tubercular splenic abscess, splenic abscess, tubercular splenic abscess Introduction Tuberculosis continues to be a major problem in India. Despite health authorities' efforts to control it, an estimated four lakh deaths occur every year. One-fifth of the global tuberculosis incidence is in India with 1.8 million cases occurring every year. [1] Extra pulmonary tuberculosis accounts for nearly 15% of tuberculosis cases and splenic tuberculosis is a very rare clinical condition. [2] We report a case of isolated splenic tuberculosis in an asymptomatic female. Case Report A 38-year-old female came to the outpatient Department of Gynecology with complaints of vaginal vault prolapse. She was a multipara, with a 17-year-old daughter and gave history of three abortions subsequently. Her hysterectomy was done one year back. There was no history of any major illness in the past. On examination the patient appeared healthy. Her systemic examination did not reveal anything abnormal. She had a soft abdomen and no palpable mass. She was nondiabetic, HIV test was nonreactive; X-ray chest and other routine investigations were normal. A preoperative ultra sonography (USG) abdomen revealed hypoechoic areas in spleen suggestive of lymphoma or abscesses [Figure - 1]. Other abdominal organs were normal. A USG guided Fine needle aspiration (FNAC) of splenic lesion yielded pus. The gram stain and aerobic culture of the pus was negative for any organisms. However, Ziehl Neelsen (ZN) stain of the pus showed the presence of a few acid fast bacilli. The organisms grew on Lowenstein Jensen medium after six weeks of incubation. The isolate was identified as Mycobacterium tuberculosis as it was a slow grower; there was absence of pigmentation; niacin and nitrate reduction tests were positive. [3] The strain was sensitive to rifampicin, INH, ethambutol, pyrazinamide, ofloxacin, ciprofloxacin, amikacin, and streptomycin. Sensitivity testing was done by absolute concentration method, except for streptomycin sensitivity, which was done by resistance ratio method. [4] The patient was treated with anti tubercular regimen, Category III (new extra-pulmonary tuberculosis, not seriously ill) of revised national TB control programme (RNTCP) with Rifampicin, INH, and Pyrazinamide under directly observed treatment (DOT)s for six months. [1] A follow-up USG showed clearing of splenic lesions [Figure - 2]. The patient came back for repair of vaginal vault prolapse after one year. After repair, the patient was discharged in a week. Discussion Spleen plays a special role in dissemination of tubercular infection. Evidence of haematogenous spread is almost always found in spleen. Tubercles are more numerous and larger in spleen as compared to other solid organs, however, clinical disease in spleen is infrequent. [5] Two forms of tuberculosis can be seen in spleen. The more common one is its involvement in miliary tuberculosis and the other form, which is rarer, is its primary involvement. [6] There are reports of splenic tuberculosis presenting as splenic abscess in immunocompetent patients. [7],[8] In the present case the patient was asymptomatic. Splenic lesion was a chance finding on abdominal USG. The splenic aspirate did not reveal any organism on gram staining. A ZN staining was not requested by the treating doctors. A suspicious smear with mononuclears prompted us to do the ZN staining. The smear was positive for acid fast bacilli. It was later grown on LJ medium and identified as Mycobacterium tuberculosis. The cytological report was consistent with tuberculosis. The diagnosis of isolated splenic tuberculosis is difficult because of vague presentations and hence it is delayed. The radiological examination often gives a clue to the diagnosis, but the findings may mimic malignancy or fungal infection. [2] A microbiological examination is necessary for a definitive diagnosis. Bacilli are scanty in extra pulmonary tuberculosis and it is difficult to get a positive smear. Molecular techniques, conventional and real time PCR have been used for detection of tubercle bacilli directly on clinical specimens. [3] Nucleic acid amplification tests (NAA) have highest sensitivity in patients with smear positive pulmonary tuberculosis. However, their sensitivity tends to be poor with smear negative pulmonary and extra pulmonary tuberculosis. [9],[10] High costs, concerns regarding reproducibility and requirement of sophisticated laboratory infrastructure are major hurdles while using NAA tests like PCR. Hence they may have limited role in resource poor, developing countries. A high index of suspicion is required while examining smears in tropical countries like India where tuberculosis is endemic. A meticulous painstaking screening could be rewarding in pus samples negative for other organisms. Culture is important as it can differentiate between the typical and atypical mycobacteria and to know the antibacterial sensitivity. In an era of molecular diagnostics, microscopy and culture confirmation could still form the corner stone in diagnosis of tuberculosis. Acknowledgement We are thankful to the Department of Microbiology, Dr. V. M. Medical College, Solapur, for confirming the diagnosis of the isolate and performing anti tubercular sensitivity testing. References
Copyright 2010 - Indian Journal of Medical Microbiology The following images related to this document are available:Photo images[mb10051f2.jpg] [mb10051f1.jpg] |
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