A healthy 51-year-old man was referred for chest computed tomography (CT) after complaining of chronic cough without history of smoking, atopy, drug treatment, or gastroesophageal reflux.
At age 19, during his army service, he developed prolonged fever (40°C), drenching sweats, weight loss, and cough. Chest X-ray revealed an extensive dense infiltrate in the right lung with negative stains of the sputum, negative cultures, and worsening despite treatment with broad-spectrum antibiotics. Suspecting a neoplasm, he underwent bronchoscopy (noncontributory) and thoracotomy with wedge resection, which demonstrated caseating granulomas. Acid-fast bacilli could not be demonstrated or grown in repeated cultures but treatment with four antituberculous drugs for a year led to a complete resolution and full recovery. His current examination and blood tests were normal. CT demonstrated chronic changes in the right lower and middle lobes and calcified granulomas in both lungs, lung hilus, and mediastinum. Surprisingly, multiple calcified granulomas were identified in the spleen and some in the liver (Figure). The cough resolved spontaneously.
Our patient had old pulmonary tuberculosis (TB; primary infection), diagnosed by highly suggestive histology coupled to the clinical presentation.
Smear and culture-negative cases (and nowadays, negative nucleic acid amplification assays) are notorious in pulmonary and extrapulmonary Mycobacterium tuberculosis infections1 and may still be encountered, mandating empirical treatment in some cases based on a strong clinical suspicion.
The CT findings revealing abdominal TB came as a complete surprise. Abdominal TB may present in 4 protean forms, including peritoneal (the most common form, usually with ascites), gastrointestinal (often in the ileocecal area), tuberculous lymphadenopathy, and visceral TB.2
Isolated involvement of abdominal solid organs is uncommon and may involve the liver, spleen, and pancreas. TB of the spleen is rare, usually found as a disseminated form of pulmonary TB (62% of the patients), commonly in patients with concomitant HIV infection (~ half of these patients).3, 4
In this patient, hematogenous spread from tubercular foci in the lung is the most likely mechanism, attesting to the severity of the initial infection and its potential of spread to distant locations, in this case, fortunately asymptomatic.
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-Ami Schattner, MDa,b, Yair Glick, MDc, Inna Kapelyan, MDd
This article originally appeared in the December 2019 issue of The American Journal of Medicine.
