Spontaneous Splenic Rupture as a Paradoxical Reaction during Treatment for Splenic Tuberculosis
A 33-year-old woman (married, homemaker) presented with frequent high-grade fever and left-sided abdominal pain that had lasted for 1 month. There was no history of cough, sputum, or any other respiratory symptoms. She had no history of diabetes, hypertension, TB, or other significant illness. Physical examination showed that her body temperature was 38℃, pulse rate 105 beats/min, and blood pressure 100/60 mm Hg. Abdominal examination revealed an enlarged and tender spleen. Routine examinations of other systems showed unremarkable findings. The patient's laboratory data showed a white blood cell count of 11,590/mm3, hemoglobin concentration 9.4 g/dL, erythrocyte sedimentation rate 30 mm/hr, and C-reactive protein concentration 9.02 mg/dL. Other biochemical parameters, including liver functions and levels of blood sugar, blood urea, and serum creatinine, were within normal limits. T-SPOT.TB assay (Oxford Immunotec, Oxford, UK) showed positive result and enzyme-linked immunosorbent assay showed that the patient was seronegative for anti-HIV antibodies. Chest radiography revealed no remarkable abnormalities. Computed tomography (CT) of the abdomen revealed multiple low-density lesions of variable size, with some septations, in the spleen (). We also observed several enlarged mesenteric lymph nodes, which showed central low attenuation with a peripheral rim enhancement, suggestive of TB lymphadenitis (). An ultrasound-guided splenic biopsy revealed inflammatory cells with focal necrosis, and results of acid-fast bacilli (AFB) staining and TB-polymerase chain reaction were negative. Laparoscopic biopsy of the small bowel mesentery was performed for differential diagnosis and to exclude malignancy. However, biopsy of abdominal lymph nodes could not be performed, because profuse bleeding was expected as a result of severe adhesion of small bowel mesentry. Histopathological examination of the biopsy specimen revealed evidence of both acute and chronic inflammation without granuloma. Our initial impression, based on the clinical and radiological findings, was splenic TB accompanied with abdominal TB lymphadenitis. We initiated antituberculous chemotherapy with isoniazid, rifampicin, ethambutol, and pyrazinamide. After 1 week of chemotherapy, the patient became afebrile and did not complain of abdominal pain. She was subsequently discharged.\nAfter 10 weeks of chemotherapy, the patient returned to the emergency department of our hospital with sudden-onset dull and aching pain in the abdominal upper left quadrant. Abdominal CT scan showed more increase in the size and number of splenic abscesses with intraperitoneal rupture (), whereas more decrease in the size and number of abdominal lymph nodes than were previously observed (). The patient did not report occurrence of recent trauma. The patient was admitted for emergency splenectomy. Gross findings included multiple yellow necrotic nodules and hemorrhagic foci with a lacerated splenic capsule (). Histopathological examination showed epithelioid granulomas composed of epithelioid cells, lymphocytes, and Langerhans giant cells with variable degree of central caseous necrosis, consistent with TB (). AFB staining and culture for TB from the splenectomy specimen were negative. Considering the clinical improvement of the patient and radiological improvement of concomitant abdominal lymph nodes, we assumed that the splenic rupture was precipitated by paradoxical reaction. Antituberculous chemotherapy was continued postoperatively without regimen change, for a total treatment time of 9 months. The patient is currently clinically disease-free for 3 months after completion of chemotherapy.