A rare presentation of splenic tuberculosis with a pseudocyst

Splenic tuberculosis is an unusual manifestation of extrapulmonary tuberculosis, especially in immunocompetent hosts. It often poses diagnostic difficulties as microbiological confirmation is not easy. In this case report, we describe a case of pseudocyst of the spleen due to tuberculosis, which is a rare clinical presentation with only one case having been reported previously. A 24-year-old immunocompetent woman presented with pain in the abdomen, vomiting and fever. On evaluation the patient was found to have a cyst arising from the spleen. Splenectomy was performed. Pathological examination of the specimen revealed a pseudocyst with granulomas and giant cells consistent with tuberculosis. Cyst fluid analysis revealed lymphocyte predominance with high adenosine deaminase levels. The patient was started on 6 months of antituberculous therapy postoperatively. On follow-up, the patient was found to have gained weight and showed signs of well-being.

A case of mass-forming splenic tuberculosis: MRI findings with emphasis of diffusion-weighted imaging characteristics

Tuberculosis remains one of the most prevalent and fatal infectious diseases in spite of considerable improvements in medical science. The diagnosis and treatment of extrapulmonary tuberculosis involving the abdomen is still complicated owing to vague or non-specific clinical features. Although rare, isolated splenic involvement is one of the important manifestations of extrapulmonary tuberculosis, and imaging suspicion of the disease is essential. We report a case of surgically confirmed mass-forming splenic tuberculosis showing a layered pattern consisting of caseous necrosis with profound restriction of water molecules surrounded by an irregular rind of granulation tissue with less diffusion restriction on diffusion-weighted magnetic resonance imaging (DWI). In the differential diagnosis of neoplastic or non-neoplastic mass-forming lesions involving the spleen, this unique DWI feature could be helpful in characterizing splenic tuberculosis. The patient has been in clinically disease free status for nearly 20 months after splenectomy.

Clinical profile of patients having splenic involvement in tuberculosis

BACKGROUND

Tuberculosis of spleen is very rare, usually seen in disseminated or miliary form of the disease and in patients having HIV infection. Splenic tuberculosis is currently described poorly in available literature.

OBJECTIVES

In this series, we analyzed the clinical profile of patients having splenic involvement in tuberculosis.

METHODS

Patients of tuberculosis (pulmonary and/or extra-pulmonary) with abnormal splenic parenchymal lesion on ultrasound were scanned in the light of demographic, clinical, radiological features, response to treatment and co-morbid illnesses. In selected eligible cases, CT scan abdomen and ultrasound guided FNAC of spelnic lesion was also done.

RESULTS

Most of the patients (62%) were in the age group of 25-50 years with male/female ratio of 3:1. Constitutional symptoms such as fever (75%), anorexia (50%), and weight loss (10%) were common presentations apart from other symptoms such as pain abdomen (62%) and distention (12%). Half of these patients also had HIV infection. 62% patients had associated pulmonary tuberculosis. Other body sites involved were ascites (50%), intraabdominal lymph nodes (37%), pleural effusion (37%), cervical lymph nodes (12%), intestine (12.5%), etc. Ultrasonographic findings were multiple splenic abscess (62%), multiple diffuse, hypo-echoic foci (25%), solitary abscess and calcified granuloma (6%). About 44% patients became asymptomatic after receiving Category I treatment under RNTCP with complete clearance of initial sonographic abnormality in splenic parenchyma.

CONCLUSION

The splenic involvement in tuberculosis seems to be more frequent in patients with HIV infection and in disseminated form of disease. Ultrasonography of the spleen is simple, easily available, affordable, non-invasive, imaging technique highly useful for the diagnosis of splenic involvement in tuberculosis. The sonographic findings should be correlated with overall clinical presentation with demonstration of tuberculosis at other body sites and image guided FNAC may be considered in cases with isolated splenic involvement.

GLS/IL-12-modified Mycobacterium smegmatis as a novel anti-tuberculosis immunotherapeutic vaccine

OBJECTIVE

To study the effects and mechanisms of recombinant Mycobacterium smegmatis (rMS) carrying pZM03 (a co-expression plasmid encoding human granulysin [GLS] and murine interleukin 12 [IL-12]) on murine M. tuberculosis infection.

DESIGN

BALB/c mice infected with M. tuberculosis were treated with normal saline, M. smegmatis, pZM03 or rMS. The number of viable bacteria in the lungs and spleens were counted to observe the therapeutic effects. The levels of IL-12 and interferon-gamma (IFN-gamma) in serum, and IFN-gamma and tumour necrosis factor-alpha (TNF-alpha) released from spleen lymphocytes were detected to observe the T-helper 1 (Th1) response. Secretory IgA (SIgA) in bronchoalveolar lavage fluid was measured to observe the mucosal immunity. The lungs and spleens were prepared for pathological analysis.

RESULTS

The rMS group showed a significantly reduced number of colony-forming units compared to the other groups. The expression of GLS in the tissue, and increased levels of IL-12, IFN-gamma, TNF-alpha and SIgA, were found in the rMS group. The pathological changes in the lungs of the rMS group were localised, while those in the control group were extensive.

CONCLUSION

rMS had immunotherapeutic effects associated with a switch to the Th1 response and the antibacterial activity of GLS.

[Spleen and medullary tuberculosis]

Spleen is a rare extra-pulmonary tuberculosis manifestation. The spleen tuberculosis is caused by the blood derivative dissemination of mycobacteria. The symptoms can suggest a hematological disease, but it is difficult to make a diagnosis, especially when there are no pulmonary changes. The case of a 27-year-old woman with unclear etiology bone marrow hypoplasia was presented. The patient experienced: fever, body weight loss, pancytopenia and spleen enlargement with numerous focal echographic changes. The splenectomy revealed in a histopathologic examination productiva caseosa tuberculosis. The bone marrow trepanobiopsy revealed as well tuberculosis changes. The antimycobacteria treatment caused an improvement of the clinical state and the regression of symptoms.

Tuberculosis of the spleen: a case report

A 40-year old Thai male presented with epigastric discomfort and weight loss without fever for 2 months. On examination, there was no hepatosplenomegaly or lymphadenopathy. His ultrasonogram showed multiple lesions in the spleen with enlarged abdominal lymph nodes. Pathology revealed caseating granulomas of the spleen and lymph nodes. No AFB were seen but PCR was positive for M. tuberculosis complex. The fever resolved within 3 days of surgery and the patient was treated with antituberculous drugs.

Unusual presentation of tuberculosis as a splenic mass

Tuberculosis is an important health problem in developing countries, with varying clinical presentations depending on the organs/systems involved. Tuberculosis is mostly seen in immuno-compromised individuals, such as those with acquired immune deficiency syndrome or malignancies. Here we report a case of a spleen tuberculoma in a 29-year-old male patient with no known immune deficiency. He first presented with abdominal pain, and subsequent ultrasonographic examination revealed a splenic lesion of 10 cm in diameter. A computerized tomography scan of the abdomen confirmed the presence of a solitary, hypodense, septated cystic lesion. Lack of evidence supporting the presence of a splenic infection or a primary/metastatic malignancy prompted explorative surgery where a septated abscess formation was discovered and splenectomy was performed. Histopathological examination revealed granulomatous inflammatory changes with Langerhans-type giant cells, which are consistent with tuberculosis. For a period of two months, antituberculosis therapy with four drugs, isoniazid, rifampicin, pyrazinamide, and ethambutol, was carried out. Pyrazinamide and ethambutol were quitted at the end of two months. Therapy with isoniazid and rifampicin was planned for an additional 10 months. We would like to call attention to yet another atypical presentation of extrapulmonary tuberculosis.

Laparoscopic Diagnosis of Splenic Tuberculosis

Isolated tuberculous splenic microabscesses are uncommon except in immunocompromized patients. The diagnosis is often made after splenectomy and histologic examination of the spleen. We report here a case of splenic tuberculosis in an immuno-competent patient. The diagnosis was made solely by laparoscopic biopsy of the spleen without the need for splenectomy. The patient was started on antituberculosis therapy with marked recovery. We believe that this might be the first reported case of isolated splenic tuberculosis ever diagnosed by laparoscopy only.

Tuberculous splenic abscess--a case report and review of literature

Splenic abscess due to tuberculosis is a rare condition and is mostly diagnosed in immuno-compromised hosts. A case of tuberculous splenic abscess detected incidentally after splenectomy without any underlying disease is reported in an immuno-competent patient.

[A clinical analysis of 57 cases of abdominal tuberculosis]

OBJECTIVE

To explore the clinical characteristics and diagnosis methods of abdominal tuberculosis.

METHODS

The clinical characteristics of abdominal tuberculosis in 57 cases proved by histopathology between 1958-2004 were retrospectively analyzed.

RESULTS

There were 39 cases of tuberculosis of the liver, 5 cases of the spleen, 8 cases of the pancreas, 3 cases of the stomach, 1 case involved both liver and spleen and 1 case involved both liver and stomach. Twenty-six patients were males and 31 female; with ages ranged from 17 to 68 years (mean 40.7 years) and most cases (71.9%) having extra-abdominal tuberculosis. Fever (75.4%), fatigue, anorexia, night sweating, weight loss (82.5%) and hepatosplenomegaly (57.9%) were the major clinical manifestations. Elevated erythrocyte sedimentation rate (ESR) (59.6%) and abdominal mass (64.9%) were found in most of the patients.

CONCLUSIONS

The diagnosis of abdominal tuberculosis should be considered in all patients with fever of unknown origin, especially in those associated with hepatosplenomegaly, increased ESR and abdominal mass. Aspiration biopsy and laparotomy can provide correct diagnosis. The disease can be effectively treated with surgical intervention and antituberculous chemotherapy.

Miliary tuberculosis not affecting the lungs but complicated by acute respiratory distress syndrome

A 61-year-old woman was admitted with fever and headache of 10-day duration. She was found to have anemia, jaundice, and signs of meningitis. The erythrocyte sedimentation rate was increased and the tuberculin skin test was positive. A provisional diagnosis of miliary tuberculosis was made and antituberculous therapy was started, although no miliary lesions were seen on chest radiography. However, her condition rapidly deteriorated with diffuse opacification of both lungs and she died on the 7th hospital day. Postmortem examination revealed miliary tuberculosis in several organs but not in the lungs with acute respiratory distress syndrome accounting for the lung pathology. It should be noted that on rare occasions the lungs may not be involved by miliary tuberculosis.

The role of RelMtb-mediated adaptation to stationary phase in long-term persistence of Mycobacterium tuberculosis in mice

Long-term survival of nonreplicating Mycobacterium tuberculosis (Mtb) is ensured by the coordinated shutdown of active metabolism through a broad transcriptional program called the stringent response. In Mtb, this response is initiated by the enzymatic action of RelMtb and deletion of relMtb produces a strain (H37RvDeltarelMtb) severely compromised in the maintenance of long-term viability. Although aerosol inoculation of mice with H37RvDeltarelMtb results in normal initial bacterial growth and containment, the ability of this strain to sustain chronic infection is severely impaired. Significant histopathologic differences were noted in lungs and spleens of mice infected with H37RvDeltarelMtb compared with controls throughout the course of the infection. Microarray analysis revealed that H37RvDeltarelMtb suffers from a generalized alteration of the transcriptional apparatus, as well as specific changes in the expression of virulence factors, cell-wall biosynthetic enzymes, heat shock proteins, and secreted antigens that may alter immune recognition of the recombinant organism. Thus, RelMtb is critical for the successful establishment of persistent infection in mice by altering the expression of antigenic and enzymatic factors that may contribute to successful latent infection.

Mycobacterial infection in natural killer T cell knockout mice

To gain a better understanding of the pathological role of natural killer (NK) T cells in murine tuberculosis, NKT knockout (KO) mice (J(alpha)281(-/-)mice) were utilized. Eight-week-old NKT KO mice of BALB/c origin and wild-type (WT) mice were infected with Mycobacterium tuberculosis Kurono strain by the airborne route using an airborne infection apparatus, and their capacity to control mycobacterial growth, granuloma formation, and cytokine production were examined. The NKT KO mice developed granulomatous lesions in the lungs; there was no statistically significant difference in pulmonary granuloma size between NKT KO and WT mice (p<0.01). The average CFU values increased 3 weeks post-infection, but decreased 9 and 11 weeks post-infection, in the lungs of NKT KO mice. When stimulated with Kurono strain in vitro, splenic cells from NKT KO mice produced less IFN-gamma than did those from WT mice. Expression of mRNA for IL-2, IL-4, IL-6, IL-10 and IL-12 p40 was slightly lower in NKT KO mice compared with WT mice. Our data indicate that NKT cells play a detrimental role in late-phase mycobacterial infection, although Th1 cells are essential in early-phase mycobacterial infection.

Vaccination of guinea pigs with DNA encoding Ag85A by gene gun bombardment

A DNA vaccine encoding Ag85A from Mycobacterium tuberculosis was administered to guinea pigs by epidermal gene gun bombardment and its protective efficacy was determined. Vaccination with Ag85A DNA twice significantly reduced the severity of pulmonary pathology and number of pulmonary colony-forming units (CFU) (p<0.01). When immunogenic synthetic Ag85A peptide was used as a booster, lung pathology was improved significantly and pulmonary CFU were reduced dramatically. Neither Ag85A DNA nor BCG Tokyo protected the guinea pigs from hematogenous spread of tubercle bacilli to the spleen because splenic granulomas without central necrosis were recognized. When the vaccinated guinea pigs were followed up for 7 months, the pulmonary lesions became fibrotic in guinea pigs vaccinated with Ag85A DNA plus Ag85A peptide, or BCG Tokyo, and no tubercle bacilli were detected. The protective efficacy of the tuberculosis Ag85A DNA vaccine was improved significantly by peptide boosting. It is concluded that dosage and peptide boosting are important in the induction of higher protective efficacy by a tuberculosis DNA vaccine.

[Isolated tuberculosis of the spleen. Report of a case]

Isolated tuberculosis of the spleen is rare and difficult to diagnose. The features and management of this disease are discussed based on one case. A 52-year-old woman, presented with fever of unknown origin and splenomegaly. Ultrasonography and computed tomography demonstrated heterogeneous areas within the spleen. The diagnosis was made by a pathologic study of a splenic fragment obtained during laparotomy. When the spleen is the only organ involved by tuberculosis, the diagnosis is usually made by a pathologic study of splenic tissue obtained during laparotomy or percutaneous needle biopsy.

Generalized tuberculosis in the acquired immune deficiency syndrome

OBJECTIVE

Generalized, or hematogenously disseminated, tuberculosis (TB) in patients with the acquired immune deficiency syndrome (AIDS) has been associated with a high incidence of cases remaining undiagnosed until postmortem. To better characterize generalized TB in the setting of AIDS, this report describes the clinical, laboratory, radiologic, and pathologic features of 20 fatal cases.

DESIGN

The medical records, autopsy protocols, and histologic material from patients with AIDS and concomitant TB were reviewed. All patients were autopsied at a tertiary care medical center during the years 1985-1997.

RESULTS

In 50% of our 20 cases, diagnosis was not made until postmortem. Signs and symptoms were few, including the absence of fever (temperature > or = 38 degrees C) in 55% of patients. Consistent laboratory abnormalities of a nonspecific nature were limited to hyponatremia (sodium <135 mmol/L) in 60%. Both peripheral and deep (thoracic and abdominal) lymphadenopathy, unusual in adults with TB, occurred in 45% and 95% of cases, respectively. In contrast to previous reports, all of the 6 cases of tuberculous meningitis presented as acute meningitis with a predominance of neutrophils in cerebrospinal fluid. Necrotizing encephalitis with extension of the acute inflammation into the superficial cortex was seen in all cases and tuberculous brain abscesses occurred in 50% of cases, a higher frequency than previously reported. Despite lung involvement in 90% of the cases, 33% of chest radiographs were interpreted as normal and disseminated mycobacterial disease was not suggested in the radiograph report in any of the other cases. Soft tissue abscesses in uncharacteristic locations such as the neck, mediastinum, and perirectal area occurred in these patients. Histologically, 95% of organs sampled showed inflammatory foci characterized by extensive necrosis with numerous neutrophils and/or karyorrhectic debris, numerous acid-fast bacilli, few or no epithelioid histiocytes, and no Langhans giant cells.

CONCLUSION

Clinically and pathologically, generalized TB in the setting of AIDS is characterized by either unusual features or a lack of the typical features described for generalized TB in patients who do not have AIDS. This absence of classic features contributes to the high incidence of cases that remain undiagnosed until postmortem examination.

Ultrasound guided fine needle aspiration biopsy of splenic lesions

Fine needle aspiration biopsy (FNAB) of focal splenic lesions has been infrequently utilized because of the risk of haemorrhage. This study was carried out to evaluate the safety and efficacy of ultrasound guided FNAB of splenic lesions. 35 patients with focal splenic lesions underwent FNAB under real-time ultrasound guidance using a free hand technique. Ultrasound findings were single or multiple focal hypoechoic lesions (n = 33), focal hyperechoic lesion (n = 1) and diffuse heterogeneous echotexture (n = 1). Aspirations were performed with 22 G spinal needles using either the subcostal or the intercostal approach. Definite cytological diagnosis was made in 22 patients (62.8%), including tuberculosis in 10 patients, lymphoma in seven patients, extramedullary haematopoiesis in two patients and aspergillosis, histoplasmosis and bacterial abscess in one patient each. FNAB was negative in 12 patients because the aspirates were either scanty or contained only blood. FNAB was falsely positive in one patient. Only one patient had significant intraabdominal bleeding, which was managed conservatively. In conclusion, splenic FNAB performed under ultrasound guidance is a safe and accurate method in the diagnosis of focal splenic lesions.

Tuberculoma of the spleen: a rare but important clinical entity

Tuberculoma of the spleen has been an extremely rare entity during the last decades in the Western world. We describe a case in a young, HIV-negative woman who was evaluated for fever of unknown origin. The workup was initially negative, and she was treated successfully with steroids and nonsteroidal anti-inflammatory analgesics. Recurrence of the fever and an abnormal CT of the abdomen lead to an exploratory laparotomy, which revealed a subcapsular caseous material containing splenic abscess. The very few cases reported in the literature, and the increasing incidence of extrapulmonary tuberculosis due to the alarming numbers of immunodeficient patients that a surgeon may encounter are also discussed.

Ultrasound guided fine needle aspiration cytology in abdominal tuberculosis

Although barium studies and CT are useful in assessing abdominal pathology in tuberculosis, imaging findings are not always specific and a histopathological or bacteriological confirmation is often required. The aim of the present study was to evaluate the role of ultrasound (US) guided fine needle aspiration cytology (FNAC) in the diagnosis of abdominal tuberculosis in patients with non-palpable lesions detected on US/CT. FNAC was performed on 31 sites in 30 patients. The sites included enlarged lymph nodes (n = 14), focal lesions in liver (n = 2) and spleen (n = 8), and thickened bowel in the ileocaecal region (n = 7). The results were classified cytomorphologically into four groups: (1) definite evidence of tuberculosis; (2) presumptive evidence of tuberculosis; (3) suggestive of tuberculosis; and (4) negative for tuberculosis. 18 of the 31 FNACs (58%) revealed a positive diagnosis of tuberculosis (definite evidence in nine patients and presumptive evidence in nine patients). 13 of the 31 FNACs (42%) showed either necrosis alone (n = 4) or negative results (n = 9). Zeihl-Neelson staining for acid-fast bacilli on direct smear was positive in only nine patients (29%). Splenic and lymph nodal FNAC had a high sensitivity (87.5% and 78.6%, respectively) in the diagnosis of tuberculosis. None of the bowel and liver FNACs was diagnostic. No complications were encountered. US guided FNAC offers a safe and accurate method of achieving a diagnosis in patients with suspected abdominal tuberculosis who present with radiologically demonstrable but non-palpable lesions, especially those involving lymph nodes and spleen.

CT findings in splenic tuberculosis

Splenic tuberculosis is rare and delay in diagnosis is common. We present two cases of splenic tuberculosis with their appearance on CT. The CT findings were multiple, round or ovoid, low-density lesions without calcification. Except for non-specific lymphadenopathy no abnormality nor history suggestive of tuberculosis was revealed prior to laparotomy. Although CT does not confirm a diagnosis of splenic tuberculosis, it would be a valuable examination to define the extent of disease and guide aspiration biopsy.

Sites of tuberculous involvement in patients with AIDS. Autopsy findings and evaluation of gallium imaging

The purpose of this study was to review autopsy and gallium scan findings in two different acquired immune deficiency syndrome (AIDS) patient populations who had a confirmed diagnosis of tuberculosis (TB) to identify organs involved and accuracy of clinical diagnosis. The first group was comprised of 29 autopsies between January 1982 and December 1994, including only 18 patients who were diagnosed before death. Organs most commonly involved were the lymph nodes (59%), lungs (56%), spleen (53%), liver (45%), and kidneys (37%). Other opportunistic infections were present in 18 (59%) of autopsies, with more than one opportunistic infection present in 11 (37%) of the autopsies. Lungs were involved in 79% of all autopsies. The second population group included 94 patients with AIDS with a proven diagnosis of TB, only 24 of whom had gallium scans in the period between January 1992 and December 1994. Chest x-ray results were negative in 4 patients (17%); gallium scan results were positive in 16 patients (66%). The reasons for false-negative gallium scan results were due to anti-tuberculous treatment for periods varying from 2-21 months in 7 patients or the presence of extra pulmonary tuberculosis. The sites of TB involvement in the chest were: lung parenchyma in 5 patients (19%, 4 in mid and lower lung, and 1 in upper fields). There was lymph node involvement in all 16 patients (24 locations with mediastinal involvement in 23%, supraclavicular 23%, axillary 11%, retroperitoneal 11%, and inguinal region in 4%. We conclude that (1) tuberculosis in patients with AIDS behaves similar to primary tuberculosis; (2) the combination of chest x-ray and gallium imaging is sensitive for the diagnosis of pulmonary tuberculosis in patients with AIDS; (3) the involvement of mediastinal lymph nodes in gallium scans in the presence or absence of chest x-ray abnormalities should raise the possibility of TB involvement in patients with human immunodeficiency virus; (4) anti-TB treatment decreases the sensitivity of gallium scan.

[A case of tubercular liver and splenic abscesses]

A 34-years male was admitted to our hospital with a hypochondria pain and low grade fever. Abdominal CT revealed an encapsulated 8 x 3 cm low density lesion on the surface of the liver (S5, S8) and multiple low density lesions of the spleen. The patient had already been treated with anti-tuberculous drugs for the past 7 months after being diagnosed as tuberculous pleuritis. Although echo-guided percutaneous needle biopsy was tried for the hepatic lesion, no special finding was obtained. Therefore a diagnostic laparotomy was performed and the hepatic lesion was resected. Abscess formation of the resected lesion was noted. Histopathology of the lesion revealed epithelioid granuloma, but microscopy, culture and PCR for tuberculosis revealed negative results. Abdominal CT, 3 weeks after surgery, revealed enlargement of the splenic lesion. Splenectomy was carried out to avoid splenic rupture. Multiple abscess of the resected spleen was noted. Pathological finding, Ziehl-Neelsen stain and PCR for tuberculosis confirmed the diagnosis of tubercular splenic and liver abscess. Although tubercular liver and splenic abscess are very rare recently, it should be included in the differential diagnosis of unknown hepatic and splenic lesions.

Microabscesses of the liver and spleen in AIDS: detection with 5-MHz sonography

PURPOSE

To determine whether sonograms of the liver and spleen, obtained with 5-MHz linear-array transducers, aid in detection of hepatosplenic microabscesses in patients with acquired immunodeficiency syndrome (AIDS).

MATERIALS AND METHODS

Abdominal sonographic examinations (n = 111) were performed in 102 consecutive patients with AIDS. A 3.5-MHz sector transducer was used in each study, with additional images of the hepatic and splenic parenchyma obtained with a 5-MHz linear-array transducer. Each study was reviewed without benefit of the 5-MHz images, and categories of the hepatic and splenic parenchyma were as follows: 1, lesions definitely present; 2, lesions possibly present; and 3, lesions absent. The 5-MHz images were subsequently reviewed, and studies were recategorized. Findings were correlated with results of pathologic examination.

RESULTS

The 5-MHz scans enabled identification of focal hepatic or splenic lesions in 14 of 96 studies placed in category 2 or 3 on the basis of the 3.5-MHz sector scans.

CONCLUSION

In patients with AIDS, 5-MHz sonograms of the liver and spleen enable detection of microabscesses not confidently identified on 3.5-MHz scans.

Tuberculosis presenting as a solitary splenic tumour

A 48-year-old male had suffered from body weight loss and general malaise for 2 months. Abdominal computed tomography showed a dilated intrahepatic duct with stones and a hypodense nodular mass in the spleen. A splenectomy and distal pancreatectomy were performed under the preoperative impression of a malignancy. Histological examination of the specimens revealed tuberculosis.

CT appearances in macronodular hepatosplenic tuberculosis: a review with five additional new cases

Pseudotumoral or macronodular hepatosplenic tuberculosis (HSTB) is rare. Only 31 cases have been documented in imaging literature so far. Presented is the clinico-imaging review with five additional new cases of this uncommon variety. Due to nonspecific wide spectrum of imaging appearances, biopsy is mandatory in almost all cases. Clinical recovery and resolution of lesions on imaging may not be directly proportional.

Ultrasound detection of tuberculomas of the spleen

A case of multiple tuberculomas of the spleen, detected as hypoechoic masses on ultrasound and subsequently proved at operation and histopathology, is presented. This was the only manifestation of the disease.

[Tuberculosis of the lymph nodes and spleen preceding Hodgkin's disease]

Tuberculosis of the lymph nodes is not rare today. However tuberculosis of the spleen has been very rare even in the past when many patients had suffered from tuberculosis. The appearance of Hodgkin's disease following tuberculosis is an extremely rare condition. It has thought that deficiency of cellular immunity was responsible for both tuberculosis and malignancy. We present a 44-year-old man in whom lymph node and spleen tuberculosis antedated the clinical onset of Hodgkin's disease for three years. The patient was successfully treated with tuberculostatics until he developed Hodgkin's disease; he was treated according to MOPP protocol. Six years after the onset of disease nodular lesion of the spleen was detected and splenectomy was carried out. The enlarged spleen, g in weight, was removed with tuberculoma in the lower pole, 4 cm in diameter. The tuberculostatic therapy for a year followed splenectomy. The patient stayed symptom-free, with no sign of tuberculosis. He is in the remission stage of Hodgkin's disease with normal clinical and laboratory data.

[Rare abdominal manifestations of tuberculosis: isolated splenic tuberculosis and peritoneal tuberculosis]

Two patients with rare localizations of extrapulmonary tuberculosis are presented. In a 55-year-old man admitted with septic fever and a low neutrophil count, ultrasonography of the spleen revealed splenomegaly with numerous hypodense foci. Fine needle biopsy of one of the foci disclosed tuberculosis. Persistent splenogenic neutropenia and thrombocytopenia, despite tuberculostatic therapy, required splenectomy which confirmed the initial diagnosis. At laparotomy no other abdominal foci of tuberculosis were found. In a second 57-year-old man admitted for ascites and weight loss, a biopsy specimen of the liver showed normal liver parenchyma but, by chance, peritoneal tuberculosis. Tuberculostatic therapy brought about cure.

[Anergic miliary tuberculosis, with principally splenic localization simulating hemolymphopathy. Report of 4 cases]

Four cases of disseminated tuberculosis with prevailing spleen involvement and lack of tuberculin reactivity are described. The atypical clinical picture justified, at the beginning of the disease, the suspect of a lymphoreticular disorder (malignant lymphoma in 3 cases) or of a pulmonary hemosiderosis (in 1 case). The splenectomy and the following anti-tubercular chemotherapy were fully successful in all 4 patients and the skin reactivity was restored. The Authors discuss the pathogenesis of the observed features and the differential diagnosis of the cases of tuberculosis with only extrapulmonary involvement. These cases represent today about 1/6 of the patients with postprimary tuberculosis.

[Isolated hepatosplenic tuberculosis: 1 case]

A 27-year-old woman presented with high spiking fevers, progressive malaise, weight loss, and marked hepatosplenomegaly. The clinical picture and laboratory findings (including hepatic scintiscan, coeliac arteriography and abdominal lymphangiography) prompted surgical exploration of hypochondriac organs. On laparotomy, both liver and spleen surface exhibited extensive inflammatory lesions. Histopathologic investigations on hepatic tissue showed microscopic caseating granulomata. Specific stains and cultures for mycobacterium, fungi etc. were negative in tissue preparations. Antituberculous and steroid therapy elicited a rapid response. Follow-up observations indicated the resolution of specific hepatic lesions.

[Bone marrow's histopathology in tuberculosis of the hematopoietic organs (author's transl)]

Through the reports of the literature, the histopathologic lesions of the bone marrow in tuberculosis of the hematopoietic organs are analysed. Whether the lesions are typical or not, it is necessary to have a bacteriologic proof of tuberculosis. Near these lesions, bone marrow's cellularity is often greater or lower, reticular fibers are often increased and sometimes reticulin fibrosis is marked. Other necrosis and granulomatous inflammation are discussed. Contribution of macrophage is described. The relationships between tuberculosis and hematologic diseases are reported.