Isolated splenic tuberculosis presenting with spontaneous rupture in an immunocompetent adolescent: a case report from an endemic area.

Introduction and importance: Tuberculosis (TB) remains a major global health concern, particularly in developing countries, where its extrapulmonary forms present diagnostic challenges. Splenic involvement is rare and can lead to life-threatening complications if not promptly recognized and managed. Case presentation: We describe the case of an 18-year-old Ethiopian male with a history of childhood TB who presented with severe left upper quadrant pain, progressive weight loss, fever, night sweats, and recurrent syncopal episodes. Despite initial intravenous antibiotic therapy, symptoms persisted. Laboratory and imaging studies revealed severe anemia, splenic hematoma, hemoperitoneum, and a splenic artery pseudoaneurysm with active bleeding. The patient underwent emergency splenectomy. Histopathological analysis confirmed necrotizing granulomatous inflammation consistent with TB. He was started on anti-TB therapy postoperatively and showed marked clinical improvement. Clinical discussion: Splenic TB is a rare manifestation of extrapulmonary TB and may mimic other splenic pathologies. In this case, the presentation with splenic hematoma and pseudoaneurysm posed significant diagnostic and therapeutic challenges. Failure to respond to broad-spectrum antibiotics and the presence of systemic symptoms emphasized the importance of considering TB in the differential diagnosis. Prompt surgical intervention combined with anti-TB therapy was critical in preventing fatal outcomes. Conclusion: This case underscores the importance of maintaining a high index of suspicion for TB in patients presenting with unexplained abdominal symptoms in endemic regions. Early recognition and timely intervention are essential to prevent serious complications such as splenic rupture and the need for emergency surgical management.