ID Case Conference January 30, 2008 Carlos M. Perez, MD, FACP Associate Professor of Medicine Pontificia Universidad Catolica de Chile

The Case HPI: 39-year-old, previously healthy woman admitted to our hospital with a 40- days history of asthenia, fever (temperature up to 39 °C), and 4 kg weight loss. Fifteen days before admission she had noted continuous pain in the left-upper quadrant of her abdomen.

The Case (continued) PMH & PSH: Unremarkable Medications: None NKDA SH: Divorced. No recent sexual partner. No Etoh abuse. No tobacco use. ROS: As described

Physical exam P: 100 x min. BP: 120/70. T: 37,5°C, RR: 18 x min. Pale, diaphoretic. No lymphadenopathy. HEENT wnl Heart and Lungs wnl Abdomen: Tenderness in the left upper quadrant and over the splenic costal area. Spleen palpable 2-3 cm below costal margin

Laboratory Hematocrit 30.1 %, leucocytes 6,200 (4 % bands), Platelets: Normal Sed rate 125 mm/h. HIV-1 (two determinations, 2 weeks apart) (-). Aglutination test for Brucella abortus (-)

Imaging Abdominal Ultrasound: Splenomegaly with multiple rounded hypoechogenic areas (3-16 mm in diameter) Abdomen CT scan: Multiple hypodense lesions in the splenn without enhancement. Liver, pancreas, and kidneys were normal.

Discussion

Clinical course Because we suspected a lymphomatous process of the spleen, a splenectomy was performed. Laparotomy revealed an enlarged spleen that weighed 200 g and had multiple, poorly defined nodules cm in diameter that appeared to be purulent.

Pathology of Spleen Pathology report: Granuloma (arrow) in the red pulp with central necrosis, persistence of celular contour and nuclear debris (A), and an outer epithelioid zone (B) consistent with chronic granulomatous necrotizing splenitis of the gummatous type. Stains and cultures for bacteria, mycobacteria, and fungi were all negative Perez C et al. Clin Infect Dis 1995;

Conclusion Isolated Gummatous Splenitis

Clinical course VDRL was weakly reactive and microhemagglutination test for Treponema pallidum (MHA-TP) was positive

Clinical course The patient received cefazolin 1 g iv qid for 5 days and then benzathine penicillin 2.4 million unit IM per week for 3 weeks. Her clinical conditions improved, fever resolved and her ESR returned to normal 3 months after surgery.

Tertiary Syphilis Late manifestations of untreated syphilis appear 8-25 years after infection and they occur in ~ 28 % of patients with syphilis. Benign, tertiary syphilitic manifestations (gummas) in bones, skin, and viscera develop in ~ 16 % of patients with syphilis. Gummatous lesions indicate a chronically progressive inflammatory reaction, usually in which there are few numbers of treponemes.

Tertiary Syphilis Gummas of the lymphoid structures are rare. The spleen can show different patterns of involvement, such as an association with hepatic gummas (hepatosplenic syphilis), disseminated amyloidosis with splenic involvement, and isolated syphilitic splenomegaly, as seen in our patient.

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