Isolated Splenic Tuberculosis in an Immunocompetent Young Woman: A Diagnostic Challenge

Isolated splenic tuberculosis (TB) is an exceptionally rare form of extra pulmonary TB, accounting for <1% of abdominal TB cases. The nonspecific clinical presentation combined with limited sensitivity of molecular tests for extrapulmonary TB often delays diagnosis and misattribution to pyogenic abscess or malignancies. We report the case of 21-year-old immunocompetent woman presenting with vague upper abdominal pain and weight loss without any constitutional symptoms. Clinical examination revealed splenomegaly without lymphadenopathy. Contrast-enhanced computed tomography revealed multiple splenic abscesses with peripheral rim enhancement and areas of splenic infarcts. Diagnostic laparoscopy revealed multiple pale nodular splenic lesions prompting need for laparoscopic splenectomy. Splenic abscess fluid was negative on GeneXpert; however, histopathological examination confirmed splenic TB with characteristic caseating granulomas and Langerhans giant cells. The patient received standard antituberculosis therapy (ATT) for 6 months with complete resolution on follow-up. This case highlights the diagnostic challenge and emphasizes the importance of maintaining high clinical suspicion despite negative molecular testing in endemic regions, even in immunocompetent individuals. Management decisions should be individualized. A comprehensive literature review is also included, demonstrating that splenectomy combined with ATT is highly effective in cases of extensive splenic disease, while medical management alone achieves good results in small uncomplicated cases.