Letter to the Editor
Isolated splenic tuberculosis in an immunocompetent patient
Tuberculosis esplénica aislada en un paciente inmunocompetente
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A 66-year-old woman, with history of high blood pressure, diabetes mellitus (DM) type 2 and idiopathic Parkinson's Disease, who presented fever during 5 weeks. She reported recurrent self-limited episodes of syncope and long-term asthenia and weight loss (more than 5<span class="elsevierStyleHsp" style=""></span>kg in 3 months). Her medical history did not reveal any allergies, occupational exposure to airway irritants or infection risk factors. Her temperature was 38.5<span class="elsevierStyleHsp" style=""></span>°C, she had high blood pressure above 160/80<span class="elsevierStyleHsp" style=""></span>mmHg and tachycardia at 101 beats per minute. Laboratory study indicated leukocyte count 7550<span class="elsevierStyleHsp" style=""></span>c/μL (reference 4–11<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>c/μL) (neutrophils 2.6<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>c/μL and limphocytes 2.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>c/μL), platelet count 539<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span> (reference 150–450<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>), hemoglobin count 11.6<span class="elsevierStyleHsp" style=""></span>g/dL (reference 12–16<span class="elsevierStyleHsp" style=""></span>g/dL) and C-reactive protein 108.7<span class="elsevierStyleHsp" style=""></span>mg/L (reference 0–5<span class="elsevierStyleHsp" style=""></span>mg/L). Renal and liver function tests and tumor markers were normal. Splenic length was 11<span class="elsevierStyleHsp" style=""></span>cm on Computed Tomography (CT) scan and ecography, multiple hypodense non-enhancing nodules were observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This suggested multiple infectious microabscesses versus neoplasm of the spleen. Successive blood, urine and stool cultures yielded no bacterial growth. Serological tests for HIV, hepatitis B and C, <span class="elsevierStyleItalic">Salmonella</span>, <span class="elsevierStyleItalic">Brucella</span>, and <span class="elsevierStyleItalic">Bartonella</span> were negative. <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> (MTB) was not detected in Ziehl-Neelsen (ZN) smears. A tuberculosis Interferon-Gamma Release Assay (IGRA) was positive. The Infectious Disease Committee decided to use empiric antimicrobial therapy against bacterial, fungal and MTB infection, as a diagnosis was yet to be confirmed. Laparoscopy splenectomy was consensually performed to confirm the diagnosis and rule out oncological disease. The histological examination revealed an expanded red pulp with the presence of granulomas, with central necrosis and cellular debries, surrounded by epithelioid histiocytes, lymphocytes and isolated eosinophils. Inmunohistochemistry and Flow Cytometry role out lymphoproliferative disorder. Ziehl-Neelsen didn’t identify acid-fast bacilli. Negativity for acid-fast bacili stains has a relatively low sensitivity and doesn’t rule out mycobacteria.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Nowadays they are mostly replaced by PCR techniques to identify the mycobacteria.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The most common anatomic sites affected by extrapulmonary TB are lymph nodes, pleura, bone and joints, urogenital tract, and meninges.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In our case, we identified isolated splenic TB nodular disease in immunocompetent patient, that is considered an infrequent finding in Spain, not considered an endemic country. Besides, there are few cases of isolated splenic tuberculosis reported in the international literature, and nearly none in western medical centers. Splenic tuberculosis is typically associated with serious systemic illnesses such as immunosuppression, bacterial endocarditis, or sepsis as a result of haematogenous spread.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Diagnosis of isolated splenic tuberculosis is made by radiologic exams confirmed by pathologic examination of fine needle aspiration, splenic biopsy or splenectomy specimen.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In our case CT scan couldn’t demonstrate an exact diagnosis or rule out malignancy, so a laparoscopic splenectomy was performed, after Infectious Disease clinicians consensus, to confirm the diagnosis. Surgical intervention in primary splenic tuberculosis is usually unnecessary as a mode of treatment. However, it can be indicated under particular conditions: diagnostic purpose (as in our case), failure of medical treatment, cytopenia or polycythemia, tuberculous splenomegaly associated to portal hypertension, failure of percutaneous abscess drainage or multiple splenic abscesses.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In the case of EPTB diagnosis, including isolated splenic disease, main experts and societies recommend a long-term antituberculous treatment (12 months: 2 initial months treatment with rifampicin, isoniazid, pyrazinamide and ethambutol followed by 10 months with rifampicin and isoniazid).<span class="elsevierStyleSup">5</span> In our case, the patient developed difficulty for oral intake of tablets, so an intravenous treatment was administrated for 15 days, followed by the consensual oral therapy. The diagnosis was further corroborated when the patient showed remarkable improvement after antituberculous treatment and completed 10 months of rifampicin and isoniazid. Evolution was satisfactory and relapse after recovery has not been identified after one-year follow-up. Isolated splenic tuberculosis is a very uncommon phenomenon, especially in nonendemic areas and immunocompetent patients. Typically, clinicians will consider more than one diagnostic hypothesis before reaching the final diagnosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 714 "Ancho" => 1005 "Tamanyo" => 114953 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT sagital section where multiple hypodense nodular lessions in spleen are observed (arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "editores" => "W.Gray" "titulo" => "Diagnostic cytopathology" "edicion" => "3th ed." 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