Korean J Gastroenterol.  2015 Sep;66(3):168-171. 10.4166/kjg.2015.66.3.168.

A Case of Splenic Tuberculosis Forming a Gastro-splenic Fistula

• Lee KJ
• Yoo JS
• Jeon H
• Cho SK
• Lee JH
• Ha SS
• Cho MY
• Kim JW

• KMID: 2373334
• DOI: http://doi.org/10.4166/kjg.2015.66.3.168

Abstract

We report a case of a 61-year-old man who presented with a cough and abdominal discomfort. CT scan of the chest showed two lesions across both lungs, and an abdominal CT scan revealed multiple hypodense lesions in the spleen with cystic lesions on the splenic hilum. Upper gastrointestinal tract endoscopy found creamy yellowish discharge through a fistula between the stomach and splenic hilum. Under fluoroscopic guidance, forceps was inserted into the fistula tract, and forcep biopsy was done. The pathology was consistent with tuberculosis, and a nine-month anti-tuberculosis medication regimen was started. Imaging performed three months after finishing medication indicated improvement of splenic lesions, and the gastro-splenic tract was sealed off. This case is a very rare clinical example of secondary splenic tuberculosis with a gastro-splenic fistula formation in an immunocompetent patient.

Keyword

Tuberculosis, splenic; Gastro-splenic fistula; Granuloma

MeSH Terms

Antitubercular Agents/therapeutic use
Fluoroscopy
Gastric Fistula/pathology
Gastroscopy
Humans
Male
Middle Aged
Spleen/diagnostic imaging/pathology
Splenic Diseases/*diagnosis/diagnostic imaging/pathology
Tomography, X-Ray Computed
Tuberculosis, Splenic/*diagnosis/drug therapy/microbiology
Ultrasonography
Antitubercular Agents

Figure

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  Fig. 1. CT images of chest and abdomen. (A) First chest scan shows two newly-developed 1.5-cm lobular consolidations in posterior segment of right upper lung and anterior segment of left upper lung. (B) Chest scan after one month of antibiotics shows mild improvement of initial chest lesion, but newly developed focal consolidation lesion on right lower lobe. (C) Final chest scan after six months of antituberculous treatment shows disappearance of focal consolidation on both upper lobe and right lower lobe. (D) First abdominal scan shows multiple focal hypodense lesions in spleen with cystic lesion on splenic hilum. (E) Abdominal scan after one month of antibiotics shows enlargement of multiple hypodense lesions on spleen. (F) Final abdominal CT scan after twelve months of antituberculous treatment shows splenic abscesses nearly healed.

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  Fig. 2. Sonographic and fluoroscopic images. (A) Abdominal ultrasonography shows multiple low echoic nodules in spleen. (B) When dye was injected through ulceration site using gastroscope under fluoroscopic guidance, there was a fistular tract between the stomach and spleen.

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  Fig. 3. Endoscopic findings. (A) Initial gastroscopy shows creamy yellowish discharge on ulceration of subepithelial mass from fundus to upper body, similar to an abscess. (B) After two months of antitubercular therapy, follow-up gastroscopy shows gastro-splenic fistular tract sealed off.

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  Fig. 4. Microscopic finding of spleen biopsy specimen shows well-defined granuloma with epithelial cells and central caseous necrosis (H&E, ×100). Finding is compatible with chronic granulomatous inflammation with caseous necrosis, suggestive of tuberculosis.

Reference

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