Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 29643 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 

CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 822-825
Spontaneous rupture of tuberculous spleen in a HIV seropositive patient on maintenance hemodialysis


1 Department of Radiology, Christian Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Internal Medicine, Christian Medical College and Hospital, Ludhiana, Punjab, India
3 Department of Nephrology, Christian Medical College and Hospital, Ludhiana, Punjab, India
4 Department of Pathology, Christian Medical College and Hospital, Ludhiana, Punjab, India
5 Department of Surgery, Christian Medical College and Hospital, Ludhiana, Punjab, India

Click here for correspondence address and email

Date of Web Publication2-Sep-2009
 

   Abstract 

Spontaneous rupture of the spleen usually occurs secondary to infection, hematolo­gical disorders or infiltrative lesions of the spleen. In patients with positive human immuno­deficiency virus (HIV) antibodies and the acquired immunodeficiency syndrome (AIDS) who pre­sent with acute abdomen, splenic rupture should be considered as a possible cause and should addi­tionally be investigated for co-infection with tuberculosis. Spontaneous rupture of spleen in asymp­tomatic patients requires a high index of suspicion for diagnosis. We herein report on a HIV-positive patient on maintenance hemodialysis, who presented with spontaneous rupture of a tuberculous spleen.

How to cite this article:
Rathore S, George P, Deodhar M, Calton N, George U, Pawar B, Sircar P. Spontaneous rupture of tuberculous spleen in a HIV seropositive patient on maintenance hemodialysis. Saudi J Kidney Dis Transpl 2009;20:822-5

How to cite this URL:
Rathore S, George P, Deodhar M, Calton N, George U, Pawar B, Sircar P. Spontaneous rupture of tuberculous spleen in a HIV seropositive patient on maintenance hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Oct 26];20:822-5. Available from: https://www.sjkdt.org/text.asp?2009/20/5/822/55369

   Introduction Top


India has about 5.2 million human immuno­deficiency virus (HIV) positive patients with a higher sero-prevalence in patients with tuber­culosis (TB) (8%) as compared to the general population (0.9%). [1] Tuberculosis is the commo­nest opportunistic disease in patients with the acquired immunodeficiency syndrome (AIDS) in India, which is not unusual considering the country's burden of nearly two million new TB patients each year. [2] Extra pulmonary infection constitutes up to 50% of TB in HIV positive pa­tients as compared to 10-15% in non-HIV posi­tive patients. [3] Splenic TB, which is extremely rare in immunocompetent individuals, may not be as rare in patients with HIV/AIDS, espe­cially in areas of high prevalence of coinfec­tion of these diseases.


   Case Report Top


A 22-year-old male patient with end stage renal disease on maintenance hemodialysis (HD) for three years was detected to be seropositive for HIV one year after being on HD. He presented with abdominal pain, low grade fever and vo­miting of two days duration. He was non­compliant with his bi-weekly dialysis schedule and had undergone HD four days earlier, with 5000 units of systemic heparinization during the procedure and no post procedural complications.

Two years prior to this, he was detected to have pleural effusion of tuberculous etiology for which he completed anti-tuberculous treatment (ATT) for six months, with good clinical res­ponse and resolution of the effusion. He was put on highly active retroviral treatment (HAART) following which the CD4 count reached 195/cu mm, a year earlier.

On examination, he was pale, tachypneic and hypotensive. The blood urea was 210 mg/dL, serum creatinine was 10.4 mg/dL, hemoglobin was 3 gm/dL, packed cell volume was 12.4%, platelet count was 1.53 lakhs/cu mm, prothrom­bin time test was 16.6 secs and control was 12 secs, the partial thromboplastin time test was 33 secs and control was 28 secs and total leukocyte count was 7000/cu mm.

Ultrasonography of the abdomen showed hepa­tosplenomegaly with a heterogeneously echo­textured spleen, ascites, left pleural effusion and bilateral small echogenic kidneys. Detailed eva­luation with CT imaging of the abdomen showed hepatosplenomegaly and bilateral small non­enhancing kidneys. Cystic areas showing hemo­rrhage within them were noted in the spleen with extension into the peri-splenic region. A large peri-splenic hematoma and ascites with fluid levels suggestive of hemoperitoneum were present [Figure 1]. Spontaneous rupture of the spleen was diagnosed and he was taken up for emergency splenectomy after resuscitation with blood transfusion, dialysis and fluid replacement.

Intra operative findings showed a large spleen ruptured along the medial surface with 750 mL of peri-splenic clots and 1500 mL of blood in the peritoneal cavity. The splenic vessels were normal. Splenectomy was uneventful and an enlarged spleen 18 × 10 × 8 cm with congestion and focal capsular rupture was seen.

Blood culture was sterile. Post operative eva­luation of the ascitic fluid showed lymphocytic predominant ascitic fluid with low serum asci­tic albumin gradient (SAAG) (serum albumin 3.8 gm/dL and ascitic albumin 3.1 gm/dL) sug­gestive of intra-abdominal infection, possibly TB. The CD4 count was 254/cu mm.

Histopathological examination of the spleen showed large areas of hemorrhage and extensive necrosis with occasional poorly formed granu­lomas comprised of epithelioid cells [Figure 2]. Acid fast bacilli (AFB) were seen on Ziehl­Nielsen staining. Tissue examination for other bacteria and fungus was negative. A diagnosis of spontaneous rupture of spleen with splenic TB was concluded. He had an uneventful recovery after splenectomy and is currently asymp­tomatic on maintenance dialysis with ATT and HAART about one year after the event.


   Discussion Top


Extra-pulmonary TB is seen in patients with advanced immunosupression as a result of HIV and is the commonest cause of pyrexia of un­known origin in such patients. [4] Splenic TB is found in severe disseminated disease, usually hematogenous in onset, and can present insi­diously often with just fever, weight loss, ano­rexia and hepatosplenomegaly. [5] It may go unre­cognized in patients unless a high index of cli­nical suspicion is exercised. Imaging with ultra­sonography and CT scan has been useful in diagnosis, [5] and less commonly histopathologi­cal confirmation is required.

Few cases have been reported where splenic involvement with TB is noted in a patient sero­positive for HIV patient; this might be in con­junction with infection at other intra-abdominal sites or rarely, in isolation. At times, splenic tu­bercular abscess may be the first presentation of AIDS. [6] Spontaneous rupture of the spleen is re­ported rarely. In patients with AIDS, it is a rare cause of emergency surgery, with only one pa­tient reported in a series of 34 emergency lapa­rotomies, over a five-year study period. [7] Sple­nic TB has also been discovered incidentally during laparotomy, [8] as in our patient who pre­sented with a life threatening complication at diagnosis. As his coagulation profile was mildly deranged and the last heparin administration was four days earlier, splenic rupture secondary to coagulopathy or heparin was considered un­likely.

In a study involving HIV positive patients with no detectable TB, on being subjected to splenic biopsy, six out of ten patients showed evidence of TB. All these patients had multiple small hypoechoeic lesions in the spleen on ultrasound examination, [9] suggesting that splenic TB might be commoner than it is thought to be. Multiple small hypoechoic lesions in the spleen in HIV­positive patients strongly suggest TB. [10] Involve­ment of the spleen in TB is suggestive of greater immunosuppression than in those pa­tients with intra-abdominal TB, whose spleen is spared. [11] Abdominal TB may be dry or wet and ascitic fluid is often helpful in diagnosis al­though staining for AFB and culture from fluid have low yields (3 and 20% respectively). Lym­phocytic predominant, low SAAG ascitic fluid is suggestive of abdominal TB, as in this patient. [3]

Spontaneous splenic rupture is uncommon and predisposing conditions include hematological diseases with splenic infiltration, splenic infarcts, male sex, massive splenomegaly, rubella and angiosarcoma of the spleen. [12] Rarely splenic tubercular abscess in an HIV-positive patient may present initially with spontaneous rupture. Occasional cases of spontaneous splenic rupture have been reported in HIV positive asympto­matic and non-thrombocytopenic patients. [13] This patient presented with an acute abdomen, and CT imaging was suggestive of splenic rupture with ascitis and hemoperitoneum. Intra-opera­tively, no gross abscesses were seen but histo­pathological examination revealed granulomas with positive Ziehl Nielsen stain for TB.

It is noteworthy that splenic TB in an other­wise asymptomatic HIV positive patient can present as an acute abdomen. Thus, tubercular splenic rupture should be considered as a diffe­rential diagnosis in such situations. This rare and cryptic presentation may be seen more fre­quently in clinical practice in future years with increase in co-infection with HIV and TB, and requires prompt and proper clinical and patho­logical evaluation.

 
   References Top

1.HIV/AIDS epidemiological surveillance and esti­mation for the year 2005, NACO, April 2006.  Back to cited text no. 1    
2.Khatri GR, Frieden TR. Controlling tubercu­losis in India. N Engl J Med 2002;347:1420-5.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Sharma MP, Bhatia V. Abdominal tuberculosis.Indian J Med Res 2004;120:305-15.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Sharma SK, Mohan A, Kadhiravan T. HIV-TB co-infection: Epidemiology, diagnosis and management. Indian J Med Res 2005;121:550­67.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Sharma SK, Smith-Rohrberg D, Tahir M, Mohan A, Seith A. Radiological manifestations of splenic tuberculosis: A 23 patient case series from India. Indian J Med Res 2007;125(5):669-78.  Back to cited text no. 5    
6.Wollf MJ, Bitran J, Northland RG, Levy IL. Splenic abscesses due to Mycobacterium tuber­culosis in patients with AIDS. Rev Infect Dis 1991;13(3):373-5.  Back to cited text no. 6    
7.Ferre C, Podzamczer D, Miro JM, et al. Emer­gency laparotomy in AIDS. Report of 35 cases from three teaching hospitals in Barcelona. Int Conf AIDS 1996;11:301.  Back to cited text no. 7    
8.Singh B, Ramdial PK, Royeppen E, Moodley J, Chetty R. Isolated splenic tuberculosis. Trop Doct 2005;35:48-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Valadas E, Badura R, Goncalves A, Quaresma MJ. Usefulness of Spleen Biopsy in the Diag­nosis of Tuberculosis in HIV Infected Patients. AIDS 2000;14(4):S129.  Back to cited text no. 9    
10.Reichel C, Theisen A, Rockstroh JK, Miller Miny H, Spengler U, Sauerbruch T. Splenic abscesses and abdominal tuberculosis in patients with AIDS. Z Gastroenterol 1996;34(8):494-6.  Back to cited text no. 10    
11.Gonzalez Lopez A, Dronda F, Alonso Sanz M, et al. Clinical Significance of Splenic Tuber­culosis in Patients Infected with Human Immunodeficiency Virus. Clin Infect Dis 1997; 24(6):1248-51.  Back to cited text no. 11    
12.Aldemir M, Suner A, Kidir V, Balakan O, celenk T. Spontaneous rupture of Spleen in a hemodialysis patient. Eur J Gen Med 2004;1 (3):51-4.  Back to cited text no. 12    
13.Pesce A, Vinti H, Taillan B, Fuzibet JG, Dujardin P, Cassuto JP. Spontaneous rupture of spleen in a HIV seropositive non thrombocytopenic patient. Int Conf AIDS 1989;5:484.  Back to cited text no. 13    

Top
Correspondence Address:
Pratish George
Department of Internal Medicine, Christian Medical College and Hospital, Brown Road, Ludhiana 141008, Punjab
India
Login to access the Email id


PMID: 19736481

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 Atraumatic spleen rupture in dialyzed patients: Clinical report and review of the literature
Piotti, G. and Filippin, F. and Rampino, T. and Bedino, G. and Bosio, F. and Morbini, P. and Gregorini, M. and dal Canton, A.
Peritoneal Dialysis International. 2011; 31(4): 486-499
[Pubmed]



 

Top
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures
 

 Article Access Statistics
    Viewed2567    
    Printed82    
    Emailed0    
    PDF Downloaded396    
    Comments [Add]    
    Cited by others 1    

Recommend this journal