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A male patient, 35 years, presented with complaints of low-grade fever, weight loss and dry cough for the preceding 15 days. On examination, pulse was 110/min, respiratory rate 30/min, and chest was clear. Liver was palpable 7 cm below right costal margin (span 18 cm). Spleen was palpable 3 cm below left costal margin.
Blood counts showed haemoglobin level of 9.0 g/dl. Sputum study for acid-fast bacilli and Mantoux test were negative.
The chest radiograph (PA view) is given in Fig 1. CT scan chest is given in Fig 2. Ultrasound of abdomen showed enlarged liver (18.2 cm), spleen (15.5 cm) and demonstrated multiple ill defined lesions measuring 3–4 mm in diameter. CT scan abdomen is shown in Fig 3.
What is the diagnosis?
Chest radiograph and CT scan chest show miliary shadows. CT scan abdomen shows multiple hypoechoic lesions in liver and spleen. This individual was a case of HIV infection. Liver biopsy showed the lesions to be tubercular granulomas with abundance of acid-fast bacilli in necrotising lesions.
HIV infection has a significant impact on the demographics of tuberculosis including miliary tuberculosis. Extra pulmonary disease occurs in more than 70% patients with tuberculosis and pre- existing AIDS . Lesions can be seen in spleen, liver, lungs, kidneys, adrenals and eyes . In majority of cases with splenic involvement, the lesions are in the form of multiple abscesses. Most often, the finding of multiple hypodense, small splenic foci is the result of granulomas or abscesses caused by Mycobacteria, Pneumocystis carinii or fungi. Similar small abscesses are frequently reported with Gram-negative infection .