Hepatosplenic Tuberculosis Mimicking Metastatic Malignancy and Immune Reconstitution Inflammatory Syndrome (IRIS) in an HIV-Positive Patient

A man in his late 30s, recently diagnosed with HIV-1, presented with persistent fever, weight loss, and fatigue, despite prior treatment for immune reconstitution inflammatory syndrome (IRIS). Imaging studies revealed splenomegaly, hepatic and splenic micronodular lesions, and pulmonary micronodules. A liver biopsy, pivotal in establishing the diagnosis, demonstrated multiple well-formed epithelioid granulomas with focal central necrosis, indicative of an infectious etiology. Polymerase chain reaction (PCR) analysis of the biopsy fragment confirmed the presence of Mycobacterium tuberculosis. The integration of histopathological findings and PCR analysis was instrumental in diagnosing extrapulmonary tuberculosis (TB) involving the liver and spleen. The patient was started on anti-TB therapy in conjunction with continued antiretroviral treatment, resulting in significant clinical improvement, with resolution of fever and weight gain. This case highlights the critical role of pathology in diagnosing extrapulmonary TB in HIV-positive patients presenting with systemic symptoms such as fever and weight loss.