Annals of Tropical Medicine and Public Health
Home About us Ahead Of Print Instructions Submission Subscribe Advertise Contact e-Alerts Editorial Board Login 
Users Online:233
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size
 


 
Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 3  |  Page : 273-277
Splenic abscesses: Reports of two cases with review of the literature


1 Department of Surgery, M. G. M. Medical College and M. Y. Hospital, Indore, India
2 Department of Surgery, M.G.M. Medical College, Mumbai, India

Click here for correspondence address and email

Date of Web Publication17-Jul-2012
 

   Abstract 

Abscess of the spleen is a rare discovery, with about 600 cases reported in the international literature so far. It is more common in the presence of infection at different primary sites, especially endocarditis or in cases of ischemic infarcts that are secondarily infected. Immunosuppression and trauma are well-known risk factors. Recently, intravenous drug abusers and alcoholics have shown an increased incidence compared to other high-risk groups. However, encountering this entity in general population is uncommon. Clinical examination and laboratory findings are not constant; thus, imaging is a necessary tool for establishing the diagnosis, with a choice between ultrasound and computed tomography. If untreated, the mortality reaches almost 100%. Treatment includes conservative measures and surgical interventions. Splenectomy has been the preferred approach in most centers. More recent studies have suggested the use of advanced and alternative options, including laparoscopic surgical and percutaneous interventions. Changing trends, in view of the importance of immunological role of spleen, have emphasized more on spleen preserving protocols, especially in children and young patients, and in cases of solitary abscess with a thick wall. conducted a literature review by analysis of various high-risk groups, presentation, diagnosis and treatment of splenic abscess, and have presented here a report of two cases.

Keywords: Percutaneous drainage of splenic abscess, post enteric splenic abscess, splenectomy, splenic abscess

How to cite this article:
Gupta S, Singh O, Hastir A, Shukla S, Mathur RK. Splenic abscesses: Reports of two cases with review of the literature. Ann Trop Med Public Health 2012;5:273-7

How to cite this URL:
Gupta S, Singh O, Hastir A, Shukla S, Mathur RK. Splenic abscesses: Reports of two cases with review of the literature. Ann Trop Med Public Health [serial online] 2012 [cited 2018 Aug 15];5:273-7. Available from: http://www.atmph.org/text.asp?2012/5/3/273/98638

   Introduction Top


Abscess of the spleen is a rare discovery, with about 600 cases reported in the international literature so far. Here, we present two cases of splenic abscess along with review of the literature. In the first mentioned case, a search to find common risk factors was negative, while the second case had history of enteric fever. In both, splenectomy was performed, followed by rapid clinical improvement. First case emphasizes that there may be additional risk factors for the development of this lesion. Changing trends, in view of the importance of immunological role of spleen, have emphasized more on spleen preserving protocols, especially in children and young patients, and in cases of solitary abscess with a thick wall. Currently, open splenectomy must be considered as the most reliable treatment of this condition and must be considered if the other available less invasive treatment methods fail.


   Case Reports Top


Case 1

A 42-year-old man presented to the surgical OPD with complaint of intermittent high-grade fever with chills and rigors, which was associated with continuous dull pain in left hypochondrial region, for last 7 days. On examination, raised body temperature with pale toxic look, mild enlargement of liver and moderately enlarged spleen could be appreciated. Chest X-ray film showed elevated left dome of diaphragm, normal lung parenchyma and clear costophrenic angles. Ultrasound of abdomen showed splenomegaly with a large hypoechoic collection measuring 15 cm × 12 cm in diameter with shaggy borders, suggestive of an abscess. Provisional diagnosis of splenic abscess was made and intravenous antibiotics were started. HIV, Widal test and tests to detect RBC sickling came out to be negative and blood culture did not reveal any microbial infection in blood. Blood investigations were significant for the presence of leukocytosis (13,400/mm 3 ) only. Contrast-enhanced computerized tomography of abdomen was performed which confirmed the diagnosis of large splenic abscess [Figure 1]. Exploration was planned and enlarged spleen with omentum wrapped around it was found [Figure 2]. Splenectomy [Figure 3] was done and his general condition improved uneventfully.
Figure 1: Abdominal CT scan of a 42-year-old man showing large solitary abscess cavity in the spleen

Click here to view
Figure 2: Intraoperative enlarged spleen of the patient in the first case, with omentum wrapped around it. Area of abscess can be seen

Click here to view
Figure 3: Splenectomy specimen of the same patient as in Figure 2. Large abscess cavity can be clearly identified

Click here to view


Case 2

A 17-year-old boy presented with pain in left upper abdominal region along with on and off fever of 4-day duration. Significant past history was that of typhoid fever 1 month back, for which he had taken treatment for 2 weeks and got cured. On examination, the patient appeared anemic and lethargic. His hemoglobin was 8.0 g/dl, total lymphocyte count (TLC) was 19,800/mm 3 and Widal test was positive. Blood culture and stool culture proved negative. Abdominal ultrasound was performed, which revealed two abscess cavities in the spleen, the larger of which was 8 cm in diameter. The chest radiograph showed mild pleural effusion. A computerized tomography (CT) scan confirmed the findings of ultrasound [Figure 4]. HIV testing, lymphoma screening and sickling test were all negative. Elective splenectomy [Figure 5] was performed which resulted in improvement in condition and an uneventful recovery.
Figure 4: Abdominal CT scan of a 17-year-old boy showing two abscess cavities in the spleen

Click here to view
Figure 5: Post-splenectomy specimen of the same patient as in Figure 4. Parenchyma has been cut to show abscesses

Click here to view



   Discussion Top


Splenic abscess is a rare clinical entity with an incidence of 0.2-0.7% in autopsy-based studies. [1] About 600 cases have been described so far in the international literature. [2] The peak age group for initial diagnosis of splenic abscesses described in the literature is 40-50 years. [3],[4] These are more commonly found in middle-aged and older individuals, with no obvious predilection for either sex. [2],[3],[5]

Various etiologies and risk factors for splenic abscess [Table 1] include infections which may be metastatic (e.g., infective endocarditis) or contiguous (e.g., colonic diverticulitis), hematological disorders and synchronous presence of conditions that compromise the immune system, such as diabetes mellitus, congenital or acquired immunodeficiency, including those with AIDS and those taking immunosuppressive therapy (e.g. for connective tissue and autoimmune disorders and after organ transplantation). [3],[4],[5],[6],[7],[8] Infective causes include typhoid, malaria, urinary tract infection, pneumonitis, osteomyelitis, otitis media, mastoiditis and pelvic infection. [9] Hematological disorders like hemoglobinopathies (especially sickle cell anemia) lead to infarction within the spleen. These infracted areas of splenic tissue may get infected and form an abscess. [9] There are many other conditions associated with splenic abscesses, including acute myeloid leukemia, pancreatitis and pancreatic adenocarcinoma and typhoid. [10] Trauma is an additional well-proved predisposing factor for splenic abscesses. [11] Intravenous drug addicts and alcoholics have been found to have an increased incidence relative to other high-risk groups. [9] Although cases of splenic abscesses have been reported in young and previously fit patients without any relevant history, [10] they are very uncommon in the general population. [2],[3],[5]

Gram-positive bacteria are the most often detected infecting microorganisms. The most common pathogens found include Staphylococcus and Streptococcus. [5],[12] Occasionally, mycobacteria, fungi, and protozoa are encountered, especially in the immunocompromised patients. [5],[12],[13],[14]
Table 1: Important etiologies and risk factors for splenic abscess

Click here to view


Splenic abscesses often present with vague or nonspecific signs and symptoms. [14],[15] The clinical manifestations of splenic abscesses usually include left upper abdominal pain, fever, nausea, vomiting and anorexia. [16],[17],[18] The diagnosis should be suspected in a patient presenting with fever, upper abdominal pain, nonspecific chest findings and leukocytosis. [3] On physical examination, tenderness over left upper quadrant area and splenomegaly are the most commonly found signs. [1] Nonspecific signs and symptomatology make the diagnosis of this rare clinical entity difficult. However, current imaging techniques are very helpful in making early diagnosis. [14],[15] Ultrasound scan, with a sensitivity of 76%, gives findings which are suggestive of an abscess cavity in the spleen. Large abscesses are easily detected, but smaller ones may be missed. [1] CT is the gold standard for definitive diagnosis with a sensitivity of 96% and specificity of 90-95%. [1] It gives the classical appearance of a hypodense lesion. Differential diagnosis of splenic abscesses in CT and US images include splenic infarct, hematoma, neoplasm and even complicated cyst. [9]

Splenic abscess is a potentially serious surgical problem, which, without adequate treatment, is associated with high mortality. [4],[19],[20] Untreated splenic abscesses may rupture into the peritoneal cavity with generalized peritonitis, or erode through the diaphragm and rupture into pleural cavity or even bowel, usually colon, and prognosis then becomes very poor. The overall mortality rate is 12.4%. [1] Post-treatment complications of splenic abscesses depend on the treatment method applied. Respiratory complications such as pneumonia, atelectasis, and pleural effusion are the most common causes of morbidity following open splenectomy. [21] Significant operative complications of laparoscopic splenectomy include pancreatic injury and pancreatitis. Other complications of splenectomy include subphrenic abscess which is a recognized consequence of gastrointestinal tract or pancreatic injury and requires prompt diagnosis and drainage. This has not yet been reported with laparoscopic procedure. [21] Knowledge of the anatomy, careful preoperative planning, optimal exposure, and attention to the details of the technique are needed to reduce the incidence of iatrogenic complications.

Due to the seriousness of this condition and potentially life-threatening complications, the most common form of treatment given is total splenectomy along with appropriate antibiotic therapy, although treatment with antibiotics alone has been done successfully. [3],[22],[23],[24] Splenectomy is still considered the standard of care for splenic abscesses. [2],[11] However, more recent studies have also referred to alternative options, including laparoscopic splenectomy and spleen preserving protocols such as percutaneous imaging-guided drainage. [2],[22],[25] These methods are minimally invasive and are expected to result in smaller operative risk and overall treatment period, although this may differ according to the exact cause of the abscess. [16],[17],[18] Percutaneous drainage is indicated, especially when patients are in critical health postoperatively or when the risks of general anesthesia, surgical drainage, or splenectomy are substantial. [26] In young patients and in children, preservation of splenic function by percutaneous drainage has a major immunological advantage. [27] Some studies suggest that percutaneous drainage with CT guidance is a safe and effective alternative to surgery, allowing preservation of the spleen and should be considered as the first line of treatment. [26] Multilocular abscesses, fungal abscesses, infected hematomas, abscesses with thick contents and abscesses unresponsive to percutaneous drainage should be subjected to splenectomy. [26] Percutaneous drainage allows early detection of causative pathogen with selection of appropriate antibiotic therapy. Also, complications from this modality appear to be rare, although there a few case reports in the literature. In one previous report of ultrasound-guided drainage, [18] the only complication in 21 cases was the development of a subcapsular hematoma following drainage, with no hemodynamic compromise. [28] Although these minimally invasive and percutaneous methods have shown good initial results and various advantages are most welcomed, the literature lacks enough experience to signify their role in splenic abscess treatment. The literature favors their use only in selected patients and in selected centers. [29]


   Conclusion Top


Splenic abscesses are rare in general population but commoner in various high-risk groups. CT scan is currently considered the gold standard to establish the diagnosis. Splenectomy has been the conventional preferred surgical approach, but recent studies are pointing toward minimally invasive and spleen preserving approaches, at least in suitable patients. No study is available to determine the most effective treatment of splenic abscess. Early diagnosis, individualized management, and increased experience with minimally invasive methods are mandatory to decrease the morbidity and mortality. In view of the diverse patient population, patient selection for a specific intervention modality is very important to improve prognosis. Currently, open splenectomy must be considered as the most reliable treatment of this condition and must be considered if the other available less invasive treatment methods fail.

 
   References Top

1.Ooi LL, Leong L. Splenic abscesses from 1987 to 1995. Am J Surg 1997;174:87-93.  Back to cited text no. 1
    
2.Carbonell AM, Kercher KW, Matthews BD, Joels CS, Sing RF, Heniford BT. Laparoscopic splenectomy for splenic abscess. Surg Laparosc Endosc Percutan Tech 2004;14:289-91.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Chiang IS, Lin TJ, Chiang IC, Tsai MS. Splenic abscesses: review of 29 cases. Kaohsiung J Med Sci 2003;19:510-5.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Chulay JD, Lankerani MR. Splenic abscess: Report of 10 cases and review of the literature. Am J Med 1976;61:513-22.   Back to cited text no. 4
[PUBMED]    
5.Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC, et al. Clinical characteristics and prognostic factors of splenic abscess: A review of 67 cases in a single medical center of Taiwan. World J Gastroenterol 2006;12:460-4.   Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Kim HS, Cho MS, Hwang SH, Ma SK, Kim SW, Kim NH, et al. Splenic abscess associated with endocarditis in a patient on hemodialysis: A case report. J Korean Med Sci 2005;20:313-5.   Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Smith MD Jr, Nio M, Camel JE, Sato JK, Atkinson JB. Management of splenic abscess in immunocompromised children. J Pediatr Surg 1993;28:823-6.   Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Swamy TK, Balachandar TG, Chandramohan SM, Manohara G, Ali MA. Splenic abscess in a HIV patient. Trop Gastroenterol 1995;16:29-31.  Back to cited text no. 8
[PUBMED]    
9.Piplani S, Ramakrishna, Nandi B, Ganjoo RK, Madan R, Chander BN. Two cases of salmonella splenic abscess. Med J Armed Force India 2006;62:77-8.  Back to cited text no. 9
    
10.Murray AW, Macgregor AB. A case of multiple splenic abscesses managed non-operatively. R Coll Surg Edinb 2000;45:189-91.  Back to cited text no. 10
[PUBMED]    
11.Ulhaci N, Meteoglu I, Kacar F, Ozbas S. Abscess of the spleen. Pathol Oncol Res 2004;10:234-6.   Back to cited text no. 11
    
12.Zacharoulis D, Katsogridakis E, Hatzitheofilou C. A case of splenic abscess after radiofrequency ablation. World J Gastroenterol 2006;12:4256-8.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Nelken N, Ignatius J, Skinner M, Christensen N. Changing clinical spectrum of splenic abscess: A multicenter study and review of the literature. Am J Surg 1987;154:27-34.  Back to cited text no. 13
[PUBMED]  [FULLTEXT]  
14.De Bree E, Tsiftsis D, Christodoulakis M, Harocopos G, Schoretsanitis G, Melissas J. Splenic abscess: A diagnostic and therapeutic challenge. Acta Chir Belg 1998;98:199-202.   Back to cited text no. 14
[PUBMED]    
15.Tikkakoski T, Siniluoto T, Paivansalo M, Taavitsainen M, Leppänen M, Dean K, et al. Splenic abscess: Imaging and intervention. Acta Radiol 1992;33:561-5.  Back to cited text no. 15
    
16.Hasan M, Sarwar JM, Bhuiyan JH, Islam SM. Tubercular splenic abscess. Mymensingh Med J 2008;17:67-9.  Back to cited text no. 16
    
17.Agarwal N, Dewan P. Isolated tubercular splenic abscess in an immunocompetent child. Trop Gastroenterol 2007;28:83-4.  Back to cited text no. 17
[PUBMED]    
18.Sharma SK, Smith-Rohrberg D, Tahir M, Mohan A, Seith A. Radiological manifestations of splenic tuberculosis: A 23-patient case series from India. Indian J Med Res 2007;125:669-78.   Back to cited text no. 18
[PUBMED]  Medknow Journal  
19.Pickleman JR, Paloyan E, Block GE. The surgical significance of splenic abscess. Surgery 1970;68:287-93.   Back to cited text no. 19
[PUBMED]    
20.Teich S, Oliver GC, Canter JW. The early diagnosis of splenic abscess. Am Surg 1986;52:303-7.   Back to cited text no. 20
[PUBMED]    
21.Gigot JF, Healy ML, Michaux JL, Njinou B, Kestens PJ. Laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Br J Surg 1994;81:1171-2.   Back to cited text no. 21
[PUBMED]    
22.Zerem E, Bergsland J. Ultrasound guided percutaneous treatment for splenic abscesses: The significance in treatment of critically ill patients. World J Gastroenterol 2006;12:7341-5.   Back to cited text no. 22
[PUBMED]  [FULLTEXT]  
23.Smyrniotis V, Kehagias D, Voros D, Fotopoulos A, Lambrou A, Kostopanagiotou G, et al. Splenic abscess: An old disease with new interest. Dig Surg 2000;17:354-7.   Back to cited text no. 23
[PUBMED]    
24.Westh H, Reines E, Skibsted L. Splenic abscesses: A review of 20 cases. Scand J Infect Dis 1990;22:569-73.  Back to cited text no. 24
[PUBMED]    
25.Martinez DG, Sanchez AW, Garcia AP. Splenic abscess after laparoscopic nissen fundoplication: A consequence of short gastric vessel division. Surg Laparosc Endosc Percutan Tech 2008;18:82-5.  Back to cited text no. 25
    
26.Fotiadis C, Lavranos G, Patapis P, Karatzas G. Abscesses of the spleen: Report of three cases. World J Gastroenterol 2008;14:3088-91.  Back to cited text no. 26
[PUBMED]  [FULLTEXT]  
27.Thanos L, Dailiana T, Papaioannou G, Nikita A, Koutrouvelis H, Kelekis DA. Percutaneous CT-guided drainage of splenic abscess. AJR Am J Roentgenol 2002;179:629-32.  Back to cited text no. 27
[PUBMED]  [FULLTEXT]  
28.Chou YH, Tiu CM, Chiou HJ, Hsu CC, Chiang JH, Yu C. Ultrasound-guided interventional procedures in splenic abscesses. Eur J Radiol 1998;28:167-70.  Back to cited text no. 28
[PUBMED]  [FULLTEXT]  
29.Tasar M, Ugurel SM, Kocaoglu M, Saglam M, Somuncu I. Computed tomography-guided percutaneous drainage of splenic abscesses. Clin Imaging 2004;28:44-8.  Back to cited text no. 29
    

Top
Correspondence Address:
Shilpi Gupta
VPO - Sangowal, Tehsil - Nakodar, District - Jalandhar - 144041, Punjab
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.98638

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]

This article has been cited by
1 Infective Endocarditis Presenting as Acute Renal Failure and Unusual Complications
Luciano Pereira,Ana Machado,Jorge Oliveira,Pedro Almeida,Paulo Bettencourt
Internal Medicine. 2015; 54(10): 1259
[Pubmed] | [DOI]
2 Aseptic Splenic Abscess as Precursory Extraintestinal Manifestation of Inflammatory Bowel Disease
Joel Brooks,Gisoo Ghaffari
Case Reports in Medicine. 2014; 2014: 1
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *


    Abstract
   Introduction
   Case Reports
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed6535    
    Printed137    
    Emailed6    
    PDF Downloaded20    
    Comments [Add]    
    Cited by others 2    

Recommend this journal