A 60-year-old male patient from Bahir Dar in the Amhara region of Ethiopia presented with low-grade fever, significant weight loss, drenching night sweating, poor appetite, exertional shortness of breath, and easy fatigability for four months. He had vertigo, blurring of vision, and tinnitus for two months. Two weeks before his hospital visit all the above symptoms worsened and also started to feel LUQ abdominal pain with a dragging sensation. Otherwise, he had no history of cough, orthopnea, body swelling, bleeding from any site, or swelling around the neck, axilla, or groin region. He drinks local alcohol frequently. He had no known chronic medical illness. He was not from the malaria and Kalazar endemic area or had no previous history of attack. For the above complaint, he repeatedly visited a private and nearby hospital and was repeatedly treated with unspecified PO and IV medications but no improvement.
On initial evaluation, he was acutely sick looking on chronic base (emaciated), pulse rate of 100 to 108 per minute, temperature of 37.9 to 38.5OC, respiratory rate of 20 breaths per minute, and normal Blood pressure and oxygen saturation. Other pertinent positive findings were pale conjunctiva, the spleen was palpable 8cm along the splenic growth line, the liver was palpable 4cm below the right costal margin and total liver span was 18cm with normal chest finding and no peripheral lymphadenopathy.
On investigation, complete blood count showed WBC of 2.9X103 with Neutrophil- 51%, Lymphocyte-35%, Hgb/Hct-6.9g/dl/19.6%, MCV-76.7fl, MCH-27.9,RDW-CV-19.6, and Platelete-38X103. The erythrocyte sedimentation rate (ESR) was 90mm per hour. HIV screening, hepatitis B surface antigen, hepatitis C virus antibody, and Rk-39 were all negative. The liver enzymes, liver function tests, renal function tests, fasting blood glucose, serum electrolytes, peripheral morphology, and bone marrow aspiration were normal. Echocardiography was normal except there was related calcification over the mitral valve. Chest x-ray (Fig. 1)-elevated left hemidiaphragm with normal parenchyma. Abdominal ultrasound showed nonspecific hepatomegaly (20cm) and splenomegaly (21cm) with a linear hypoechoic area seen at the upper pole of the spleen, likely infarctions and also a few small periportal Lymphadenopathy. Abdominopelvic CT scan (Fig. 2) showed that the liver was 20.4cm in size and the parenchyma had homogenous intermediate attenuation or mass. In a post-contrast study, there was no abnormal parenchymal enhancement. The spleen was 22cm in size, with homogenous intermediate soft tissue density and there was 4.6cm splenic laceration in the upper 3rd of the spleen associated with 13.4cm by 3.4cm measuring intermediate density(about 59HU) focus on the anterior medial aspect of the spleen which was sub-capsular hematoma. There were also discrete mildly enlarged pre-aortic lymph nodes largest measuring 1.7 cm in size.
After a thorough evaluation, we considered extrapulmonary tuberculosis, and anti-TB was started with 2RHZE/4RH and pyridoxine. Then on his 1st month of follow-up after anti-TB initiation; he had no fever, abdominal pain, night sweating, or cough. His easy fatigability decreased and he started to gain weight with an improved appetite. On investigation, normal Complete blood count except that the hemoglobin was 9.5g/dl, and abdominal ultrasound showed hepatomegaly (17.2cm but decreased in size from the previous) with smooth counter and splenomegaly (18cm but decreased in size from the initial size) with upper pole sub-capsular hypoechoic collection. Then Anti-TB continued and on 2nd month of follow-up all his symptoms improved, and on investigation normal complete blood count and abdominal ultrasound; The Liver was normal in size homogenous echo-pattern, and smooth contour. No focal lesion was seen. The spleen was enlarged (16.5 cm), had a homogenous echo pattern, and no focal lesion was seen. After that, we continued anti-TB with the 4RH regimen and he was appointed at the end of 6 months of treatment. At 6-month evaluations, all his symptoms improved with normal physical findings, and all the investigations were normal. We declared a cure and discharged him from follow-up.