Splenic abscess is not an uncommon entity in tropics. In Indian subcontinent, where the incidence of enteric fever is high, abscess formation in spleen is frequently seen in clinical practice. In view of immunological functions, splenic preservation is preferred over splenectomy, especially in children and young adults. Medical management with antibiotics alone is considered inadequate for management of splenic abscess. Hereby, we report an unusual case of complete resolution of a florid splenic abscess with antibiotics alone without the need for any invasive intervention.
Keywords: Antibiotic, percutaneous drainage, splenectomy, splenic abscess
Splenic abscess is a potentially life-threatening condition and is uniformly fatal if left untreated. In the past, splenectomy was considered the “gold standard” for the management of splenic abscess. , However, in recent years, the nonoperative management has gained favor and is now considered the standard approach.  Here, we describe a case of splenic abscess in a young boy which was managed successfully with antibiotics alone.
A 14-year-old boy presented to us with complaints of intermittent high-grade fever, abdominal pain, and anorexia for 1 month. There was no history of vomiting, diarrhea, jaundice, or any trauma in the recent past. Patient had no known medical comorbidities, and there was no history of intravenous drug abuse. He was initially treated elsewhere with no significant clinical improvement. On physical examination, the patient was febrile with pallor and tachycardia. Per-abdominal examination revealed a tender splenomegaly without any other lump or ascites.
Abdominal ultrasonography (USG) which was done prior to presentation showed a hypoechoic lesion of 62 mm × 53 mm × 52 mm in the spleen, suggestive of an abscess. Rest of the examined organs including liver, biliary tract, and portal vein were normal. Laboratory evaluation showed low hemoglobin (9.3 g/dl) with normal total (4.1 × 10 9 /L) and differential leukocyte counts (neutrophils – 74%, lymphocytes – 26%). General blood picture was that of microcytic hypochromic anemia with normal platelet count. Hepatic and renal function tests were normal.
Computed tomography (CT) scan of the abdomen showed a moderate splenomegaly with a well-defined heterogeneous peripherally enhancing cystic lesion (40 mm × 45 mm × 48 mm size) in the lower pole of spleen with thickening and stranding of perisplenic fat planes [Figure 1]. Hematological and immunological workups including sickling test were within normal limits. Widal serology was negative, and blood culture was sterile. Echocardiography showed no evidence of bacterial endocarditis. Thus, no specific etiology could be established in this case. Patient was started empirically on intravenous amoxicillin-clavulanic acid (1.2 g, eight hourly) with plans for percutaneous drainage (PCD) under radiographic guidance in case of inadequate response. Patient showed symptomatic improvement within 72 h, and PCD was deferred. Patient was switched on to oral amoxicillin-clavulanic acid (625 mg TDS) after 7 days and was discharged from hospital on 10 th day in an asymptomatic state.
Follow-up abdominal USG on 14 th day of therapy showed a resolving abscess measuring 22 mm × 32 mm × 29 mm in the lower pole of spleen. Patient was symptom-free and thus antibiotic was stopped, and monthly follow-up was advised. CT scan obtained at 1 month follow-up showed a hypodense lesion of 8 mm × 10 mm × 10 mm size at the lower pole of the spleen [Figure 2]. Patient was symptom-free with complete resolution of an abscess at 1-year follow-up.
Spleen is an uncommon site for abscess formation with <1000 cases reported in the literature.  The increasing incidence of splenic abscess in recent years has been implicated to the rising prevalence of AIDS, diabetes, intravenous drug abuse, and chemotherapy regimens for various malignancies.  Till two decades back, most of the splenic abscesses were secondary to typhoid or malaria. Finally, bacterial infection has been reported to be the most common cause. Fungal or tubercular abscesses are only rarely encountered, especially in immuno-compromised patients.  However, our patient was immuno-competent and otherwise healthy young boy, and despite extensive evaluation no specific underlying cause could be established. We speculate that previous subclinical enteric fever, which is quite common in India, might be the underlying cause. Widal test is only moderately sensitive with positivity in 65-70% of culture proven typhoid cases. 
Our patient presented with fever, abdominal pain, and splenomegaly. Sarr and Zuidema reported fever and left abdominal pain in 91.7% and 63.9% of patients with splenic abscess respectively.  In another study by Ooi and Leong,  splenomegaly was present in 60% and left upper quadrant tenderness in 58.3% of cases. Leukocytosis in splenic abscess is observed in up to 90% of cases though in our patient leukocyte count was normal.  In the current patient, repeated blood cultures were sterile. Blood culture has been reported to be useful in only 50% of cases with splenic abscess. 
Abdominal USG has a diagnostic sensitivity of 75-90%. Typically, the abscess appears as a focal echo-free defect or as a lesion with solid and cystic components. Abscess wall usually appear thick and irregular and may contain echo-free debris or septations.  CT scan is the imaging modality of choice with sensitivity of 96% and specificity of 90-95%. , It may also help to differentiate splenic abscess from other diseases such as a splenic cyst or infarct and can also be used to serially monitor the response to therapy.
Traditional treatment for splenic abscess has been splenectomy and antibiotic therapy. , Ooi and Leong suggested that PCD of abscess may be equally effective with lesser procedure related mortality and morbidity.  Currently, splenectomy is reserved only for persistent or recurrent splenic abscess not responding to PCD.  Antibiotic therapy alone is usually considered inadequate for the management of an overt splenic abscess. However, some recent series have reported successful treatment of splenic abscess with antibiotics alone.  In our case, the patient had overt symptoms and CT findings of a large abscess in the spleen. Considering the important immunological function of the spleen, young age of the patient, and absence of any predisposing factor, splenic preserving approach was opted.
Although medical treatment alone has been considered inadequate for the treatment of splenic abscess, selected patients may be amenable to such approach. Prerequisites for a trial of antibiotic treatment alone include absence of any predisposing conditions and favorable initial response to therapy. Such trial may avoid more invasive and morbid procedures like PCD or even splenectomy. Possible drawbacks of this approach may be the burden of prolonged admission, cost of treatment, and risk of recurrence.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]