Annals of Tropical Medicine and Public Health

CASE REPORT
Year
: 2012  |  Volume : 5  |  Issue : 3  |  Page : 273--277

Splenic abscesses: Reports of two cases with review of the literature


Shilpi Gupta1, Onkar Singh1, Ankur Hastir2, Sumit Shukla1, Raj Kumar Mathur1,  
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

Correspondence Address:
Shilpi Gupta
VPO - Sangowal, Tehsil - Nakodar, District - Jalandhar - 144041, Punjab
India

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.



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;5:273-277


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 2020 Sep 22 ];5:273-277
Available from: http://www.atmph.org/text.asp?2012/5/3/273/98638


Full Text

 Introduction



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



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}{Figure 2}{Figure 3}

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}{Figure 5}

 Discussion



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}

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



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.

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