PROF.DR.G.SUNDARAMURTHY’S UNIT

-DR.K.SENTHAMIZH SELVAN

AN INTERESTING CASE OF FEVER

Saravanan 30yrs/male manual labourer thirvottriur

CASE DETAILS

pt presented with c/o fever - 2 months H/O PRESENT ILLNESS : - H/O fever -2 months,low grade,continuous

fever , not ass. With chills and rigor - H/O vague left upper abd discomfort- 1

month , dull aching ,not radiating ,no agg & relieving factors

HISTORY

H/O loss of weight ,around 10 kgs ,in the past 2 months.

H/O loss of appetite + H/O easy fatiguability + no h/o cough with expectoration /

altered bowel habits no h/o jaundice no h/o abd distension,leg swelling no h/o oral ulcers ,joint pains, swelling,

discoloration of extremities ,joint stiffness

no h/o of skin rashes

no h/o bleeding diathesis no h/o dysuria

no h/o seizures no h/o altered sensorium

no h/o chest pain ,palpitation ,breathlessness

PAST HISTORY : - not a known

SHT/T2DM/BA/epileptic/CKD

- no h/o contact with open case of PT

- no h/o ATT

- no h/o blood transfusion/surgery

PERSONAL HISTORY: - occasional alcoholic,not a smoker

- no h/o sexual promiscuity

FAMILY HISTORY: - Not contributary

ON EXAMINATION

Pt was conscious oriented febrile hydration fair Pallor + no icterus/cyanosis/clubbing no SGLA no PE no skin rash no sternal tenderness

VITALS : pulse -92/min ,regular BP-110/70 mm Hg CVS: S1S2+ no murmur RS: NVBS+ no added sounds

P/A: soft splenomegaly+, 5cm below LCM firm, tender no free fluid BS+CNS : clinically normal

PROBLEMS

fever , 1 month

loss of wt./loss of appetite

anaemia

splenomegaly

POSSIBILITIES

-- chronic malaria

-- hematological disorder

-- immunocompromised state

WORK UP

urine routine – alb-nil sug -nil dep-2-3 pus cells/hpf urine c&s – no growth Bleeding time-2 min clotting time-4 min PT-14 sec aPTT-34sec INR-1.2

CBC

14/12/10 28/12/10 7/1/11

TC 4,200 3,100 2,200

DC P64/L35/E1 P66/L33/E1 P56/L34/E10

RBC count 3 million/cumm

2.6 million/cumm

1.8million/cumm

Hb 9.4gm% 8.7gm% 7.4gm%

ESR 20/38 28/56 80

Platelet count 2.4 lakh/cumm 1.8lakh/cumm 1.3lakh/cumm

PERIPHERAL SMEAR

23/12/10 2/1/11

Normocytic ,normo chromic anaemia Platelets adequateShift to left,no blasts

Normocytic,hypochromic RBC sPlatelets adequateShift to left No blasts

LFT: T.bilirubin-1.14mg/dl direct bilrubin-0.56mg/dl SGOT-35.7 SGPT-32.9 Alkaline phosphatase-181 RFT: Blood sugar-124mg/dl blood urea-15mg/dl s.creatinine-0.7m/dl

CHEST X RAY

FEVER PROFILE

MP QBC- negative Blood widal-negative Dengue serology- negative MSAT-1+ HIV elisa-non reactive VDRL-negative HBsAG-negative Anti HCV-negative Blood c&s- no growth

ECG- WNL

ECHO- no RWMA - normal LV systolic function - no vegetations

USG ABDOMEN

---- splenomegaly 19.6 cms multiple hypo echoeic ill defined

lesions of varying sizes throughout the spleen ,

no significant calcification ---- liver normal sized normal echo texture,no focal abnormalities ---- multiple small peripancreatic ,

portal ,hilar nodes , largest node-11×7mm

CECT ABDOMEN

DIFFERENTIAL DIAGNOSIS

INFECTION/INFLAMMATION: - pyogenic abscess,fungal

abscess,granulomatous infection ,hydatid cysts CYSTIC NEOPLASM: -

lymphangiomatosis,lymphomas,cavernous hemangioma NECROTIC METASTSIS: - malignant melanoma,breast,lung ,ovary SARCOIDOSIS:

BONE MARROW STUDY

---- Normal marrow precursors, no

immature cells, myeloid: erythroid ratio of

5:1

sputum AFB- negative

Mantoux- negative.

S. calcium – 9 mg/dl

24 hr urine calcium- 110mg ( Normal range 100-300mg)

S.ACE levels- 34u/l ( Normal range 10-60 u/l)

---IgM antibody to brucella – 1:10 (normal > 1:320)

what next ?

USG GUIDED FNAC

---- smear showed clusters of

epitheliod histiocytes,admixed with mature and reactive lymphocytes , with caseating zones in the background

!? Granulomatous lesion, with caseating zones

PROBLEMS

fever -2 months.

significant loss of weight/appetite.

anaemia.

splenomegaly.

Rapidly progressing Bi-cytopenia

FNAC evidence of granulomatous lesion with caseating zones.

?

FINAL DIAGNOSIS

“SPLENIC TUBERCULOSIS”

--- CAT -1 ATT was started for the

patient , fever subsided completely within 2 weeks

FOLLOW UP

--- patient turned up after 2 months

improved GC

improved body wt

CBC: TC-6500cells/cumm DC-66/32/2 RBC count -3 million/cumm Hb-9.6 gm/dl ESR- 10/22 Platelet count -1.5 lakh/cumm

Rpt. USG abdomen- splenomegaly decreased (15cms.) - hypoechoeic lesions disappeared

significantly - peripancreatic ,portal nodes not visualised.

FEW CASE REPORTS

Sato T, Mori M, Inamatsu T, Watanabe J, Takahashi T, Esaki Y.

Department of Medicine, Tokyo Metropolitan Geriatric Hospital.

A case of splenic tuberculosis is reported. The patient was a 79-year-old man who was admitted to the Tokyo Metropolitan Geriatric Hospital because of high fever and loss of body weight. Several finger-tip sized superficial lymph nodes were palpable in bilateral inguinal regions. The computed tomogram of the abdomen showed moderate enlargement of the spleen with multiple low density areas and several swollen lymph nodes in the para-aortic region. Although a lymph node of the inguinal region was resected for the pathologic examination, it showed no specific changes. In order to obtain a final diagnosis, laparotomy was performed. The spleen was markedly enlarged and nodular in appearance. No abnormal findings were observed in the other abdominal organs. Splenectomy was carried out. Numerous yellowish nodules, varying from 0.1 to 5 cm in diameter, were observed on the cut surface of the resected spleen (20 x 20 x 8 cm, 700 g). Recently, isolated tuberculosis of the spleen has become very rare. Since 1965, only six cases in five reports can be found in the English, French and German literature. The present case is considered to be one such very rare cases of tuberculosis. Although splenic tuberculosis is rare at the present time, splenic tuberculosis should be included in the differential diagnosis of fever of unknown origin with splenomegaly.

PMID: 1614011 [PubMed - indexed for MEDLINE]Free Article

Isolated Tuberculosis of the Spleen: A Rare Clinical Entity Citation: S. Dalal, Nityasha, R. S. Dahiya & Prashant : Isolated Tuberculosis

of the Spleen: A Rare Clinical Entity . The Internet Journal of Surgery. 2008 Volume 16 Number 1

Adil et al. reported a series of 12 immunocompetent individuals with splenic tuberculosis but all of them had one or more extra site of tuberculous involvement along with the spleen. 5 Generally, these cases present with mild pyrexia and chronic weight loss and are diagnosed during investigational work up for PUO. Rarely, splenic tuberculosis has also been diagnosed incidentally during laparotomy that was carried out for abdominal trauma.

1. Ho PL, Chim CS, Yuen KY. Isolated splenic tuberculosis presenting with pyrexia of unknown origin. Scand J Infect Dis 2000; 32: 700-01. (s)

2. Sambrook J, Frisch EF, Maniatis T. Molecular Cloning. A laboratory manual. Vol. II, 2nd edition. Cold Spring Laboratory Press, 1989. (s)

3. Eisenach KD, Crawford JT, Bates JH. Repetitive DNA sequences as probes for mycobacterium tuberculosis. Journal of Clinical Microbiology 1988; 26: 2240-45. (s)

Indian J Med Res 125, May 2007, pp 669-678

Radiological manifestations of splenic tuberculosis: A 23-patient case series from India

S.K. Sharma, Duncan Smith-Rohrberg+, Mohammad Tahir, Alladi Mohan++ & Ashu Seith*

Departments of Medicine, *Radiodiagnosis, All India Institute of Medical Sciences, New Delhi,+AIDS Program,

Department of Internal Medicine, Yale University School of Medicine, New Haven & ++Sri Venkateswara

Institute of Medical Sciences, Tirupati, India

SPLENIC TUBERCULOSIS

TB of spleen can occur 1) disseminated TB 2) isolated splenic TB Not uncommon in HIV setting. Very rare in immuno-competant individuals. In disseminated TB 1)lung-100% 2)liver -80% 3)lymphnode -55% 4)bone marrow-40% 5)spleen-30%

Clinical presentations

pyrexia of unknown origin

chronic LUQ pain

wt. loss

unexplained anaemia

mass abdomen

splenomegaly –hypersplenism can mimic hematological disorders.

management

search for evidence of TB else where USG/CECT abdomen –1)hypoechoiec lesions diffuse- in TB coalescent –in

sarcoidosis 2)large isolated

tuberculoma Histopathological examination Microbiological examination ( AFB demonstration, AFB culture)

ATT – short course chemotherapy

- extended regimen for 1 year

Splenectomy

CARRY HOME POINTS

Isolated splenic TB is very rare in immuno-competent individuals

Still it should be considered in D/D of PUO regardless of HIV status---in Indian scenario

CECT is a very good screening tool

Tissue diagnosis forms the main stay of diagnosis

ATT +/- splenectomy --- treatment options

THANK YOU