Isolated splenic tuberculosis: A case report

We present a rare case of a 36 year old man who presented with recurrent fever but no other symptoms. Laboratory data provided no specific information for diagnosis. Abdominal ultrasonography revealed splenomegaly with multiple small hypoechoic lesions within the spleen. Computed tomography of abdomen showed a hypodense diffuse lesion. A diagnosis of isolated splenic tuberculosis was confirmed after a splenic puncture and histopathological examination.     

Lethal extrapulmonary mycobacteriosis

A 60 yr old previously healthy man was treated for gradually elevating fever and rash followed by leucopenia and mycosis of the gastrointestinal tract; he died within 6 weeks of the first symptoms appearing. Histologic examination revealed disseminated tuberculosis of paratracheal lymph nodes, liver, spleen and bone marrow with the presence of acid fast bacilli by smear examination. Multiple colonies of the same strain of Mycobacterium kansasii were isolated by bacteriological examination of lymph node and spleen tissue. Neither macroscopical nor histological examination showed any evidence of lung tuberculosis. The final diagnosis of the described acute disease and rapid death was stated as generalized extrapulmonary mycobacteriosis, which is a rare observation.     

Primary splenic diffuse large B-cell lymphoma in a patient with thymus Rosai-Dorfman disease

Rosai-Dorfman disease (RDD) is a rare macrophage-related histiocytic disorder that occurs primarily in lymph nodes or extranodal sites. Primary splenic lymphoma is an even rarer form of malignant lymphoma exhibiting characteristic diagnosis, treatment and outcome that have been poorly documented. Documentation of a rare case of primary splenic diffuse large B-cell lymphoma concomitant with isolated thymus RDD is reported in a 42-year-old male patient who was admitted to our hospital for persistent fever and splenomegaly after diagnostic thymectomy. On pathological review of the patient's resected thymus tissue, notable characteristics of thymus RDD were observed. The patient's condition quickly deteriorated, and the spleen progressively enlarged over the course of steroid treatment in our facility. Subsequent diagnostic splenectomy results indicated that non-Hodgkin's lymphoma (nongerminal center diffuse large B-cell lymphoma) was present in splenic tissues. Results of the current case study suggest that early exclusion of possible lymphoma is necessary in RDD patients who exhibit limited or no response to steroid therapy.     

Case of liver tuberculosis requiring differentiation from liver metastasis of cancer

A 79-year-old woman was admitted to our hospital because of general fatigue. Chest radiograph and computed tomograph showed bronchiectasis and centrilobular nodules in the right middle lobe and lingula, which had not changed from previous examination. Intrahepatic nodular lesions and swelling of the left cervical lymph nodes, supraclavicular lymph node, abdominal paraaortic lymph nodes and inguinal lymph nodes was observed. Biopsy specimen of the liver lesion demonstrated epithelioid cell granulomas. Biopsy of the right inguinal lymph node demonstrated epithelioid cell granulomas with caseous necrosis and culture of the specimen showed Mycobacterium tuberculosis. The patient was diagnosed as having liver tuberculosis and multiple tuberculous lymphadenitis. Antituberculous treatment with isoniazid, rifampicin, ethambutol and pyrazinamide were started and continued for 6 months. All lesions improved after treatment. This was a rare case of liver tuberculosis that was difficult to distinguish from liver metastasis of cancer.     

A case of esophageal tuberculosis which developed during the treatment for tuberculous lymphadenitis

A 23-year-old man was admitted to the other hospital complaining of fever and lymph node swelling in the left neck. Computed tomography showed swollen mediastinal lymph nodes without intrapulmonary lesions. Mycobacterium tuberculosis were identified by sputum culture and cervical lymph node biopsy and the case was diagnosed as tuberculous lymphadenitis. Three weeks after starting treatment with four anti-tuberculous drugs, he complained chest pain while eating and chest X-ray showed a new infiltrative shadow in the right cardiophrenic angle, then he was admitted to our hospital. Esophagoscopy revealed a deep ulceration with fistulas at 30 cm from the incisor and he was diagnosed as esophageal tuberculosis by histological examination of the biopsy specimen showing remarkable leukocytes infiltration and epithelioid cell granulomas with a few multinucleated giant cells. After antituberculous chemotherapy for six months, the mediastinal and cervical lymphadenopathy were reduced in size and the esophageal ulceration almost disappeared. Although esophageal tuberculosis is rare, the disease might develop during or after mediastinal or periesophageal tuberculous lymphadenitis.     

Tuberculosis of the spleen: a case report

A 40-year old Thai male presented with epigastric discomfort and weight loss without fever for 2 months. On examination, there was no hepatosplenomegaly or lymphadenopathy. His ultrasonogram showed multiple lesions in the spleen with enlarged abdominal lymph nodes. Pathology revealed caseating granulomas of the spleen and lymph nodes. No AFB were seen but PCR was positive for M. tuberculosis complex. The fever resolved within 3 days of surgery and the patient was treated with antituberculous drugs.     

Splenic abscesses due to Mycobacterium tuberculosis in patients with AIDS

Among 60 patients with AIDS seen at our institution, two had splenic abscesses due to Mycobacterium tuberculosis without pulmonary tuberculosis. In both cases splenic abscess was the first manifestation of AIDS; the patients had prolonged fever and had lost weight and experienced malaise; slight hepatomegaly was noted in both instances and peripheral lymphadenopathy in one. Chest radiography gave normal results in one case and showed hilar lymphadenopathy in the other. Ultrasonographic findings were characteristic: homogeneous hepatomegaly and splenomegaly, with multiple filling defects of variable size. Diagnosis required splenectomy in one case and biopsy of cervical lymph nodes in the other. In both cases Ziehl-Neelsen staining gave positive results; M. tuberculosis grew from a culture of splenic tissue of one patient and from a culture of lymph nodal tissue of the other. There was a rapid response to antituberculous therapy. Splenic tuberculosis seems to be a distinct extrapulmonary entity in patients with AIDS. Ultrasonographic images are useful for diagnosis and follow-up.     

Case of disseminated tuberculosis complicated with tuberculous meningitis while investigating an abdominal lymphadenopathy

In February 2005, a 33-year-old man visited A hospital complaining of fever. The blood screening test revealed the liver dysfunction, then computed tomography showed swelling of abdominal lymph nodes. In April, headache and disorientation appeared. He was diagnosed as disseminated tuberculosis and tuberculous meningitis based on chest X-ray and computed tomography findings and examination of cerebrospinal fluid. After admission to our hospital, anti-tuberculous drugs were prescribed, but the cerebral infarction happened. The disturbance of consciousness and the left half of his body paralysis appeared. They did not improve and hydrocephalus was complicated in August, though he was treated by steroids. He needed all helps because of the left half of his body paralysis and an advanced sequelae was left. It was thought that the abdominal lymph adenopathy preceded as one of symptoms of the disseminated tuberculosis in this case. It is said to be rare that abdominal lymph node swelling is seen in the early stage of disseminated tuberculosis. But, we think that it is necessary to keep in mind that the possibility of disseminated tuberculosis as one of the diseases in differential diagnosis, when we examine enlargement of abdominal lymph nodes with symptoms suggesting the presence of infection such as fever.     

Paravertebral extramedulary hematopoiesis arising with osteopetrosis tarda

Extramedullary hematopoiesis predominantly occurs in the liver, spleen, and lymph nodes with hemolytic anemia. Occurrence with osteopetrosis tarda in the paravertebral region is very rare. We discuss the examination of the third known case of paravertebral extramedullary hematopoiesis arising with osteopetrosis tarda.     

Tuberculous liver abscess not associated with lung involvement

Hepatic tuberculosis is one of the uncommon forms of extrapulmonary tuberculosis. We report a 78-year-old woman who developed tuberculous liver abscesses with splenic abscess not associated with pulmonary foci. Ultrasonography and computed tomography of the abdomen showed the low-density lesions in the liver and spleen. Histopathology of specimens obtained by percutaneous needle biopsy revealed coagulation necrosis and epithelioid cells but not tumor cells, suggesting tuberculosis infection in the liver and spleen. Systemic chemotherapy with anti-tuberculous agents led to the improvement of the lesions in the liver as well as spleen. Although tuberculous liver abscess is a very rare case, it should be included in the differential diagnosis of unknown hepatic mass lesions.     

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of peripancreatic tuberculous lymphadenitis

The percentage of patients with atypical extrapulmonary forms of tuberculosis has been increasing. Among extrapulmonary tuberculosis cases, tuberculosis of the pancreas and peripancreatic lymph nodes is a rare clinical entity. Here, we present a case of peripancreatic tuberculous lymphadenitis diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) both cytologically and microbiologically. A 23-year-old man had a 1-week history of epigastralgia and low-grade fever. Subsequently, he was found to have an abnormality on abdominal ultrasound. A computed tomography scan of the abdomen showed a solitary mass consisting of multiple cystic components with rim enhancement in the peripancreatic portion contiguous to the gall bladder. Endoscopic ultrasound-guided fine-needle aspiration was performed to confirm the diagnosis. The cytological examination revealed epithelioid cells with caseous necrosis, indicating tuberculosis. The aspirated fluid was positive by polymerase chain reaction (PCR) analysis and culture for Mycobacterium tuberculosis. Antituberculosis therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide was started based on the PCR and cytology results, and a good response to the treatment was noted. Endoscopic ultrasound-guided fine-needle aspiration cytology with PCR analysis is very useful for the diagnosis of peripancreatic tuberculosis.     

Hodgkin's disease presenting with progressive liver failure

We report an unusual case of a 70-year-old man with a diagnosis of Hodgkin's disease, who presented with fever and liver dysfunction. A few cervical lymph nodes, less than 1 cm in diameter were palpable, but other lymph nodes were not detected even by CT scan. Blood cell counts showed thrombocytopenia (platelet counts 6.8 x 10(4)/microliter), and some values for liver enzymes were out of the normal range (AST 56 U/l, ALT 87 U/l, LDH 347 U/l, ALP 1,529 U/l, and gamma-GTP 190 U/l). Abdominal CT scan showed diffuse enlargement of the liver and spleen. Endoscopic retrograde biliary cholangiopancreatography was performed because of progressive jaundice, but no abnormality was found in the biliary tract. A few granulomas were observed in bone marrow clot specimens, but tumor cells were not detected. A diagnosis of Hodgkin's disease was established by a cervical lymph node biopsy. Chemotherapy was immediately instituted, and both the jaundice and fever improved dramatically. Because cervical lymph nodes were not detected at one month after the onset and liver dysfunction appeared before cytopenia, it is suggested that the site of the primary lesion in this case was the liver.     

Littoral cell angioma presenting as metastatic thyroid carcinoma to the spleen.

Papillary thyroid carcinoma (PTC) commonly metastasizes to cervical lymph nodes. Distant metastases are unusual with the lungs most frequently involved. Well-differentiated thyroid carcinoma very rarely presents with metastases to the spleen. This is the case of a 25-year-old man with a history of PTC (1.4 cm primary; no capsular invasion and negative lymph node metastases). One year after initial surgery, recurrent disease was found in multiple neck nodes by central neck dissection. Whole body scan (WBS) following a therapeutic ablation dose of 150 mCi I(131) revealed mediastinal metastases. Computerized axial tomography (CT) of the chest one year later showed no gross mediastinal or pulmonary disease. However, multiple large splenic lesions were incidentally noted. Evaluation by ultrasound (US) showed lesions to be solid echogenic masses without remarkable Doppler characteristics to suggest vascular tumors. US-guided percutaneous fine-needle aspiration biopsy (FNAB) of one lesion was nondiagnostic. After withdrawal from Levothyroxine, serum TSH was >100 mU/L with a thyroglobulin of 9.4 ng/mL and negative anti-thyroglobulin antibodies. Diagnostic WBS revealed faint splenic uptake but was otherwise unremarkable. Following treatment with 192 mCi I(131), WBS demonstrated increased activity in the mediastinum as well as in the spleen suggesting mediastinal and splenic metastases. Contrast CT of the abdomen showed multiple low-attenuated heterogeneously enhancing splenic masses, normal liver and no intra-abdominal lymphadenopathy. The largest mass (4.5 x 3.5 cm) was exophytic and in close proximity to the splenic capsule. Despite the serum thyroglobulin of only 9.4 ng/mL, the finding of I(131) accumulation within solid splenic masses led to a preoperative diagnosis of thyroid carcinoma metastases. To establish the diagnosis and to remove the risk for splenic rupture, a laparoscopic splenectomy was performed. Histopathologic analysis showed large littoral cell angiomas (LCA). False-positive radioiodine scintigraphy in the setting of PTC involving a vertebral hemangioma has been reported. To our knowledge, this is the first case that describes multiple angiomas mimicking metastatic thyroid carcinoma to the spleen. In one-third of all cases reported, LCA co-exists with various visceral organ cancers or malignant lymphoma. This is the first report of an association between LCA and thyroid carcinoma.     

Pedunculated hepatocellular carcinoma and splenic metastasis

Only a few cases of pedunculated hepatocellular carcinoma (P-HCC) have been reported in the literature. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes,kidney, bone marrow and adrenals. Metastasis to spleen is mostly via hematogenous metastasis, direct metastasis to spleen was very rare. We report a case of P-HCC presenting as a left upper abdominal lesions which involved the spleen that was actually a P-HCC with splenic metastasis. This case is unique as P-HCC directly involved the spleen which is not via hematogenous metastasis.     

Primary signet-ring cell carcinoma of the colon at early stage： A case report and a review of the literature

A 67-year-old man, who had undergone surgery to resect multiple gastric cancers 4 years ago, visited our hospital for surveillance colonoscopy. Colonoscopy revealed a discolored, 7-mm in diameter, flat-elevated lesion with central depression in the transverse colon near the splenic flexure. Although the findings of endoscopy and barium enema were suggestive of submucosal invasion, the patient chose to undergo endoscopic mucosal resection. Pathological examination of the resected specimen revealed signet-ring cell carcinoma and a positive surgical margin. A second operation was performed, and no residual tumor or metastasis to lymph nodes was found in the resected specimens. Primary colorectal cancers composed of signet-ring cell carcinoma detected and treated at an early stage are extremely rare. We present a case and review the literature.     

Anal metastasis from rectal adenocarcinoma

The metastasis of rectal cancer to the anus is rare. Here, we report a case of advanced rectal cancer, which had a diffuse venous invasion with anal metastasis and multiple lymph node and liver metastases. The patient was a 72-year-old woman who complained of perianal pain and fresh blood in the stools for 6 months. She had neither history of fistula-in-ano nor anal surgery. Digital examination revealed a 2-cm tumor at the 7 o’clock position, and the barium enema and colonoscopy confirmed advanced rectal cancer. Abdominal computed tomography revealed thickness of the upper rectum wall, right inguinal lymph node of 10 mm and multiple liver metastases. Laparoscopically assisted anterior resection, anal tumor resection, and right inguinal lymph node resection were performed, and the histopathological examination of the resected primary and metastatic tumors confirmed similar findings of moderately differentiated adenocarcinoma, suggestive of metastasis of the rectal cancer to the anal region. In the next procedure, she had the liver lesions resected. This case suggested the importance of the careful examination of the anus during colonoscopy, or digital examination for the detection of anal metastasis.     

Splenic Infarction after Epstein-Barr Virus Infection in a Patient with Hereditary Spherocytosis

We describe the first patient with hereditary spherocytosis (HS) known to have developed splenic infarction following infectious mononucleosis (IM). An 18-year-old Japanese man was referred to our hospital in November 2004 because of continuous fever and icterus. He had undergone cholecystectomy at the age of 14 years. On patient admission in November 2004, a physical examination showed marked hepatosplenomegaly, icterus, and jaundice. He had a white blood cell count of 14.9 x 10(9)/L with 9.5% atypical lymphocytes, a red blood cell count of 2.93 x 10(12)/L, and a hemoglobin concentration of 7.8 g/dL. Microspherocytes were observed in the patient's peripheral blood smear, and immunoglobulin M antibody to Epstein-Barr virus (EBV) viral capsid antigen was detected. The patient's diagnosis was HS with IM. On day 4 of admission, the patient complained of severe abdominal pain. Abdominal computed tomography scanning revealed findings of splenic infarction. Two months after the occurrence of splenic infarction, a splenectomy was performed. A pathohistologic examination of the resected spleen revealed no evidence of thrombosis or arterial occlusion. We assume that the cause of splenic infarction was insufficient blood flow to oxygenate the entire spleen during the acute enlargement of the spleen.     

Bacteroides (Parabacteroides) distasonis splenic abscess in a sickle cell patient

Splenic abscess is not an uncommon complication of patients with sickle-cell disease. Here we describe an 18 year-old boy with sickle cell disease and left upper quadrant abdominal pain. Computerized axial tomography revealed left sided free flowing pleural effusion and splenomegaly with liquefaction and possible gas formation. The splenic fluid grew an unusual organism known as Bacteroides distasonis. The patient received antimicrobial therapy and underwent a splenectomy with full recovery. The spleen was cystically infarcted and measured 22 x 16 x 5 cm. The capsule was thickened and covered by fibrinous exudate. Histopathologic examination of the spleen showed complete necrosis with reparative fibrosis. This case presents an unusual cause of splenic abscess due to Bacteroides distasonis with a subacute to chronic course. The presence of fever and left sided pleuritic chest pain in patients with sickle cell disease should raise the suspicion of splenic abscess.     

Inflammatory pseudotumor of the spleen with EBV positivity: report of a case

Inflammatory pseudotumor (IPT) of the spleen is a rare benign tumor with unknown etiology. It causes problems in the diagnosis because of mimicking some hematopoetic malignancies. Here we report the case of a 36-yr-old woman complaining of nausea and insomnia. Laboratory investigations were limited to increase of leukocyte and thrombocyte count. Ultrasonography and magnetic resonance (MR) imaging showed circumscribed solid lobulated mass, measuring about 6.5 cm in diameter, located in the dorsal region of the spleen. Splenectomy was performed with the differential diagnosis including hamartoma and lymphoma of the spleen. Histological examination of the sharply demarcated splenic mass consisted of myofibroblasts and admixture of inflammatory cells. Immunohistochemistry and in situ hybridization were performed. IPT of the spleen was diagnosed. Epstein-Barr virus (EBV) was detected in the tumor by in situ hybridization. This rare entity is presented because of its clinical, radiological and pathological difficulties in the differential diagnosis.     

Pancreatic tuberculosis with obstructive jaundice—a case report

Isolated pancreatic tuberculosis (TB) is very rare and its treatment somewhat controversial. We report a case of pancreatic TB diagnosed as pancreatic carcinoma. An 82-yr-old man presented with right upper abdominal pain and obstructive jaundice, without fever or weight loss. Ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography showed a mass lesion in the pancreatic head, which caused stricturing of the distal common bile duct and pancreatic duct in the head of the gland. As malignancy was suspected, he underwent a Whipple procedure (pancreaticoduodenectomy). Histological examination of the resection specimen disclosed typical features of tuberculosis in the pancreatic head, lymph nodes, and at the ampulla of Vater. The rest of the abdominal cavity was unremarkable. After receiving antimicrobial therapy for tuberculosis for 6 months, he remains well, without jaundice or a recurrent mass visible by ultrasound.