Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2009  |  Volume : 20  |  Issue : 5  |  Page : 822--825

Spontaneous rupture of tuberculous spleen in a HIV seropositive patient on maintenance hemodialysis


Shubhra Rathore1, Pratish George2, Michael Deodhar3, Nalini Calton4, Uttam George1, Basant Pawar3, Pankaj Sircar5,  
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

Correspondence Address:
Pratish George
Department of Internal Medicine, Christian Medical College and Hospital, Brown Road, Ludhiana 141008, Punjab
India

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;20:822-825


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 Dec 3 ];20:822-825
Available from: https://www.sjkdt.org/text.asp?2009/20/5/822/55369


Full Text

 Introduction



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



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



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.

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