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Splenic Abscess

Spleen Abscess

Splenic abscess is a rare but possibly life-threatening condition that can be caused by various Gram-positive and Gram-negative bacterial pathogens. Fever, abdominal pain, nausea, vomiting, and a poor general condition in severe cases is the typical clinical presentation. Underlying immunosuppression or the presence of comorbidities such as diabetes mellitus significantly increase mortality rates. Clinical, imaging and microbiological studies are necessary to make the diagnosis.


Presentation

Despite the fact that a splenic abscess is rarely encountered in clinical practice, the importance of early recognition lies in the fact that mortality rates are as high as 47% despite treatment, whereas virtually all patients die in the absence of proper therapy [1]. Many studies have confirmed that the presence of one or more comorbidities, such as diabetes mellitus, endocarditis, pancreatitis, liver disease, and various disorders causing immunosuppression (including human immunodeficiency virus infection and hematologic malignancies) predisposes to a poorer prognosis [2] [3] [4] [5]. A splenic abscess can be seen in patients of all ages, but middle-aged and older adults comprise the majority of cases [2] [3] [6] [7]. In addition, some reports have established a slight predominance toward male gender [2] [3] [4] [5]. The clinical presentation starts with a fever of unknown origin, sometimes with chills, that is accompanied by abdominal pain in the majority of cases [2] [6] [7]. Pain is usually confined to the upper left quadrant, but diffuse, as well as left chest wall pain, have been described in a significant number of cases [2] [3] [5] [7]. Nausea and vomiting are important constituents of the clinical presentation as well [2] [7]. Splenomegaly, although frequently present, is not always observed during the physical examination [5].

Splenomegaly
  • In view of the clinical finding of splenomegaly, she had an ultrasound and, subsequently, a CT of the abdomen, which revealed a large splenic abscess.[ncbi.nlm.nih.gov]
  • Computerized axial tomography revealed left sided free flowing pleural effusion and splenomegaly with liquefaction and possible gas formation. The splenic fluid grew an unusual organism known as Bacteroides distasonis.[ncbi.nlm.nih.gov]
  • He was initially diagnosed as having splenomegaly due to Plasmodium vivax (P. vivax), but was later found to have a splenic abscess due to Escherichia coli (E. coli). This was successfully managed by catheter drainage (CD) and antibiotic treatment.[ncbi.nlm.nih.gov]
  • Splenomegaly was present in 12 (67%), leukocytosis in 9 (50%), and thrombocytosis in 12 (67%) patients. Associated diseases were thalassemia (1), tuberculosis (1), and typhoid fever (9). Solitary and multiple SAs were seen in equal numbers.[ncbi.nlm.nih.gov]
  • Splenomegaly on abdominal examination was present in 12 patients. 15 (88 %) children were managed conservatively; however, 2 children required surgical intervention.[ncbi.nlm.nih.gov]
Tender Spleen
  • She had normal heart sounds, a palpable but non-tender spleen and was febrile. Investigations The chest X-ray on admission supported the clinical diagnosis of consolidation in the right middle and lower lobe.[casereports.bmj.com]
Fever
  • There are reports from different geographic areas on splenic abscesses associated with typhoid fever. We reported ruptured splenic abscess presenting with peritonitis as a rare and grave complication of typhoid fever.[ncbi.nlm.nih.gov]
  • Fever, abdominal pain, nausea, vomiting, and a poor general condition in severe cases is the typical clinical presentation.[symptoma.com]
  • Abstract Patients with cat-scratch disease (CSD), which is caused by Bartonella henselae, typically present with local lymphadenopathy with a brief period of fever and general symptoms.[ncbi.nlm.nih.gov]
  • Presenting symptoms included fever, abdominal pain, and anorexia. Splenomegaly was present in 12 (67%), leukocytosis in 9 (50%), and thrombocytosis in 12 (67%) patients.[ncbi.nlm.nih.gov]
  • Children presenting with non-specific high grade fever vomiting and abdominal pain should be evaluated for SA. Timely ultrasound and CT scan will lead to earlier diagnosis.[ncbi.nlm.nih.gov]
Malaise
  • We describe the case of a 79-year-old man who presented with general malaise and a high fever. The physical examination findings were unremarkable. Of note, the lymph nodes were not enlarged.[ncbi.nlm.nih.gov]
  • Common symptoms were fever (92.6%), abdominal pain (55.6%) and malaise (29.6%). Majority of patients (89%) had leukocytosis and 63% patients had associated diseases with which they were admitted.[ncbi.nlm.nih.gov]
  • Case Report A 35-year-old non-diabetic woman from a middle-class family presented with a 3-month history of low-grade fever off and on, malaise, and weight loss. Fever was associated with night sweats.[ijmm.org]
  • […] he was none the less at risk as the defects in cellular immunity that exposes to TB in HIV infection is both quantitative and qualitative. [17] The clinical manifestations of TB splenic abscess are usually nonspecific but may include; PUO, anorexia, malaise[ssajm.org]
Constitutional Symptom
  • It is noteworthy that this abscess was minimally symptomatic, with no fever or constitutional symptoms.[ncbi.nlm.nih.gov]
Chest Wall Pain
  • Pain is usually confined to the upper left quadrant, but diffuse, as well as left chest wall pain, have been described in a significant number of cases. Nausea and vomiting are important constituents of the clinical presentation as well.[symptoma.com]
Abdominal Pain
  • Fever, abdominal pain, nausea, vomiting, and a poor general condition in severe cases is the typical clinical presentation.[symptoma.com]
  • One month before, the patient presented with persistent abdominal pain. After received anti-infection therapy, the subjective symptoms eased slightly, but recently he suffered from intermittent abdominal pain again.[ncbi.nlm.nih.gov]
  • Children presenting with non-specific high grade fever vomiting and abdominal pain should be evaluated for SA. Timely ultrasound and CT scan will lead to earlier diagnosis.[ncbi.nlm.nih.gov]
  • Two days after admission he developed generalized abdominal pain and distension. Pain was not associated with vomiting. Patient was transferred to surgical unit for features of peritonitis.[ncbi.nlm.nih.gov]
  • The commonest clinical features are high grade fever and exclusively localised left upper quadrant abdominal pain.[ncbi.nlm.nih.gov]
Left Upper Quadrant Pain
  • When such patients have fever and left upper quadrant pain, splenic abscess should be considered.[ncbi.nlm.nih.gov]
  • Fever, leukocytosis and left upper quadrant pain are suggestive, but the signs and symptoms of splenic abscesses are often non-specific. Rare is the onset with diarrhoea as in our case.[ncbi.nlm.nih.gov]
  • A 40-year-old woman was admitted to Nippon Medical School Hospital because of pyrexia and left upper quadrant pain, which had persisted despite antibiotic treatment.[ncbi.nlm.nih.gov]
  • METHODS: We present the case of a 59-year-old male patient with dull left upper quadrant pain, leukocytosis, and anemia. A splenic abscess described as an air-fluid level with splenocolic fistula was found on CT scan imaging.[ncbi.nlm.nih.gov]
  • We report a case of a 60-year-old female who presented with shortness of breath and left upper quadrant pain and was diagnosed with splenic abscess associated with colon cancer. This type of presentation necessitates an early surgical intervention.[gastrores.org]
Recurrent Abdominal Pain
  • A retrospective review of three children was managed for splenic abscess in our institution.All three patients presented with pyrexia, weight loss, and recurrent abdominal pain for more than six weeks.[ncbi.nlm.nih.gov]
  • A retrospective review of three children was managed for eplenic abscess in our institution.All three patients presented with pyrexia, weight loss, and recurrent abdominal pain for more than six weeks.[afrjpaedsurg.org]
Left Flank Pain
  • Splenic abscesses should be considered as a possible source of infection in patients presenting with unexplained fevers and left upper quadrant or left flank pain.[mja.com.au]
Epigastric Pain
  • Case Report A 63 years old male presented to our emergency department with history of epigastric pain and fever of 3 weeks duration.[tropicalgastro.com]
Tachycardia
  • On examination, he was found to have a fever (temperature, 39.3 C), sinus tachycardia (heart rate, 154 beats/min), tachypnoea (respiratory rate, 28 breaths/min), hypotension (blood pressure, 97/66 mmHg), decreased breath sounds at the left base of his[mja.com.au]
  • On physical examination, the patient was febrile with pallor and tachycardia. Per-abdominal examination revealed a tender splenomegaly without any other lump or ascites.[atmph.org]
  • Failure of antibiotic treatment is indicated by deteriration in the condition of patient with increasing spikes of fever, marked tachycardia, localized guarding in the left hypochondrium and signs of overwhelming peritonitis.[jemds.com]
  • Tachycardia is usually present. The classic abdominal signs are tenderness on palpation, guarding and rebound tenderness. The tenderness will be maximal over the area of pathology.[patient.info]
  • Pyrogens injected may cause fever, tachycardia, and tachypnea within 10-20 minutes of injection, the so-called “cotton fever.” This tends to be a self-limited phenomenon.[ahcmedia.com]
Left Shoulder Pain
  • We present a case of a 21-year-old woman admitted to the emergency department with the chief complaint of left shoulder pain related to splenic abscess.[ncbi.nlm.nih.gov]
Altered Mental Status
  • Abstract The case of a 66-year-old woman with untreated diabetes mellitus who was admitted to our hospital with a fever, hypotension and an altered mental status is herein reported.[ncbi.nlm.nih.gov]

Workup

The life-threatening risk of a splenic abscess must be considered by the physician in the differential diagnosis of unexplained fever, upper left quadrant abdominal pain, and confirmed immunosuppression [7]. For this reason, a properly obtained patient history is of critical importance. Furthermore, a detailed palpation of the abdomen can aid in identifying the underlying cause. Auscultation of the lungs is very important, as both dullness and rales may be heard in the left basilar region [5]. The next step is a full laboratory workup where leukocytosis is a common finding [2] [3] [5]. Blood cultures or microbiological investigation of aspirated abscess material is recommended, and principal pathogens that have been identified in the literature include Gram-positive (Streptococci, Staphylococci, Enterococci) and Gram-negative (Enterobacteriaceae, Brucella, etc.) bacteria [4] [5] [7] [8] [9]. Imaging studies, however, are the cornerstone in solidifying the diagnosis. Abdominal ultrasonography, often chosen as the first-line study, can reveal solitary (or less commonly multiple) abscesses in the splenic parenchyma [1] [3] [4] [6]. Pleural effusions and infiltrations of the lower lungs are additional findings on ultrasonography, but also on plain radiography, although nonspecific findings are more common on a chest X-ray [5] [7]. Computed tomography (CT) is performed as a superior method to confirm an abscess in the spleen and is thus considered the gold standard of splenic abscess imaging [1] [3] [5] [10].

Left Pleural Effusion
  • X ray A plain abdominal radiograph can show a Soft tissue mass in the left upper quadrant, displacement of the gastric bubble, elevation of the left hemidiaphragm or a left pleural effusion.[3].[explainmedicine.com]
  • pleural effusion. 3 We report the case of a 5-year-old patient presenting with short-term fever and abdominal pain 2 weeks after a diagnosis of gastroenteritis due to Salmonella spp.[archbronconeumol.org]
  • pleural effusion and splenomegaly (both 27 patients), all of which were present in our patient.[mja.com.au]
  • In a retrospective study of 75 cases, splenomegaly was found only in 41 cases. (2) Left pleuritic pain and reactionary left pleural effusion can be seen. Irritation of under surface of diaphragm can lead to left soulder tip pain or hiccoughs.[jemds.com]
  • pleural effusion and atelectasis, etc., if the liquid appears in the spleen was specific for the signs, but this situation is relatively rare , Barium meal show the stomach and transverse colon to the right front of the shift, the stomach has a large[healthfrom.com]
X-Ray Abnormal
  • Abscesses near the diaphragm may result in chest x-ray abnormalities such as ipsilateral pleural effusion, elevated or immobile hemidiaphragm, lower lobe infiltrates, and atelectasis. CBC and blood cultures should be done.[merckmanuals.com]
Thrombocytosis
  • Two months later he developed recurrent thrombophlebitis and fatal thromboembolism associated with thrombocytosis.[annals.org]
  • Splenomegaly was present in 12 (67%), leukocytosis in 9 (50%), and thrombocytosis in 12 (67%) patients. Associated diseases were thalassemia (1), tuberculosis (1), and typhoid fever (9). Solitary and multiple SAs were seen in equal numbers.[ncbi.nlm.nih.gov]
  • Peripheral blood film confirmed neutrophilia and thrombocytosis. This finding was persistent on repeated samples. The patient was treated for pneumonia with intravenous antibiotics as per hospital guidelines.[casereports.bmj.com]
Pseudomonas
  • […] by contiguity, infection secondary to splenic infarction, splenic trauma, or immunodepression. 2 The microorganisms identified in the majority of the series are most frequently aerobes (streptococcus, staphylococcus, Escherichia coli , enterococci, Pseudomonas[elsevier.es]
  • Gram negative bacilli like the Escherichia Coli, Klebisiella Pneumonie and Pseudomonas Aeruginosa are occasionally predominant. (4) Salmonella strains can be seen as the offenders in endemic areas of Typhoid fever. (5,6,7) Isolated tuberculous abscess[jemds.com]
  • Patients previously given antibiotics or those who have hospital-acquired infections should receive drugs active against resistant aerobic gram-negative bacilli (eg, Pseudomonas ) and anaerobes.[merckmanuals.com]
  • […] ramosum infection in an immunocompetent elderly patient , J Clin Microbiol , 2003 , vol. 41 (pg. 2223 - 6 ) 25 Splenic abscess due to Clostridium difficile , J Infect Dis , 1983 , vol. 147 pg. 1105 26 Splenic abscess due to Clostridium difficile and Pseudomonas[academic.oup.com]
  • A multitude of other bacteria, including human oropharyngeal flora, Pseudomonas species, Acinetobacter, and Candida, have been isolated.[ahcmedia.com]
Clostridium Perfringens
  • The most frequently cultured organisms include Clostridium perfringens, Alpha-Hemoliticus Streptococcus, gram-positive Staphylococcus, gram-negative Salmonella, Candida, and Aspergillus.[ncbi.nlm.nih.gov]
Brucella Abortus
  • KEYWORDS: Brucella abortus; Brucellosis; endocarditis; splenic abscess; treatment[ncbi.nlm.nih.gov]

Treatment

  • Most of the patients could be cured with non-operative treatment. Splenectomy is a safe procedure for patients with abscess size more than 10 cm and patients not responding to non-operative treatment.[ncbi.nlm.nih.gov]
  • KEYWORDS: Brucella abortus; Brucellosis; endocarditis; splenic abscess; treatment[ncbi.nlm.nih.gov]
  • Treatment should be customized for each patient.[ncbi.nlm.nih.gov]
  • Antibiotics are inadequate as a sole treatment, and percutaneous drainage is usually only a temporary solution. Splenectomy is still the standard treatment in most cases. 2015 BMJ Publishing Group Ltd.[ncbi.nlm.nih.gov]
  • There was no response with antibiotics and surgical treatment was required. On the basis of this case and the literature review we consider that surgical treatment must be considered in patients with splenic abscess due to Brucella infection.[ncbi.nlm.nih.gov]

Prognosis

  • Although splenectomy controls local splenic suppuration, the ultimate prognosis rests on the underlying process predisposing the patient to development of splenic infection.[mayoclinic.pure.elsevier.com]
  • But owing to imaging technique, diagnosis and prognosis have improved nowadays.[ijamhrjournal.org]
  • […] one or more comorbidities, such as diabetes mellitus, endocarditis, pancreatitis, liver disease, and various disorders causing immunosuppression (including human immunodeficiency virus infection and hematologic malignancies) predisposes to a poorer prognosis[symptoma.com]
  • The presence of hepatic and/or splenic abscesses does not necessarily worsen the prognosis, but it may influence the decision on further chemotherapy and antimicrobial treatment.[ncbi.nlm.nih.gov]

Etiology

  • Abstract Splenic abscess is an uncommon entity in children, more so of tubercular etiology in immunocompetent patients. The few cases reported have usually revealed solitary abscesses in the spleen.[ncbi.nlm.nih.gov]
  • PURPOSE: To describe the demographics, clinical features, etiology, imaging findings, bacteriologic profile, treatment and outcome in patients presenting splenic abscess in a European tertiary hospital.[ncbi.nlm.nih.gov]
  • We report a single-center experience with emphasis on their diagnosis, etiology, treatment, and outcome. METHODS: This is a retrospective review.[ncbi.nlm.nih.gov]
  • We could not find out the etiology and pathophysiologic mechanism of splenic abscess in our patient.[ijamhrjournal.org]
  • With a sensitivity of 96%.[3].Gray-scale US imaging of a splenic abscess is not specific; the image shows a hypo-echoic lesion with a thick irregular wall, but this aspect may vary depending on the etiology and the size of the lesion.[explainmedicine.com]

Epidemiology

  • The aim of this article is to review the pathogenesis, epidemiology, diagnostic modalities and methods of treatment for this disease. Different imaging modalities facilitate diagnosis, with computed tomography being the cornerstone.[link.springer.com]
  • Time-trends in the epidemiology of peptic ulcer bleeding. Scand J Gastroenterol . 2005; 40 :914–20. 3. Sharma SS, Mamtani MR, Sharma MS, Kulkarni H.[tropicalgastro.com]
  • Epidemiology The incidence depends on the cause. In a hospital setting the prevalence of SBP is around 10%. [ 3 ] Three studies of patients with perforated appendicitis found an incidence of postoperative abscess formation of 20%.[patient.info]
  • References 1 Clostridium difficile : recent epidemiologic findings and advances in therapy , Pharmacotherapy , 2007 , vol. 27 (pg. 1029 - 39 ) 2 Biology of Clostridium difficile : implications for epidemiology and diagnosis , Annu Rev Microbiol , 2011[academic.oup.com]
Sex distribution
Age distribution

Pathophysiology

  • We could not find out the etiology and pathophysiologic mechanism of splenic abscess in our patient.[ijamhrjournal.org]
  • […] diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment , not a consequence of a medical assessment. for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology[allnurses.com]
  • The pathophysiology of splenic abscesses is still poorly understood, it may be better defined by the progress of medical imaging, however, three hypotheses as to it origin are still discussed: Hematogenous: comes from other infective focus through blood[ghrnet.org]

Prevention

  • The clinical presentation and management of this case is reported and comments are made on surgical aspects of SGV division during fundoplication to prevent this potentially dangerous situation.[ncbi.nlm.nih.gov]
  • If the patient's general state allows it, it is best to perform splenectomy prior to valve replacement surgery to prevent re-infection of the valve prosthesis. A combined one-stage procedure is also an option.[ncbi.nlm.nih.gov]
  • Splenic artery ligation is one of the least invasive measures to prevent occurrence of this syndrome. Despite its potentially devastating consequences, splenic infarction following splenic artery ligation has received little attention to date.[ncbi.nlm.nih.gov]
  • Primary Prevention Primary prevention for splenic abscess can prevent in specific cases especially patients who are at high risk such as immunocompromised patients (e.g. recipients of renal transplants or patients on immunosuppressive drugs for other[wikidoc.org]
  • Prevention Prevention of spleen abscess 1, active treatment of infectious diseases, strengthen the anti-antibiotic treatment; 2, for abdominal trauma, especially the spleen by blunt injury or penetrating injury, should be debridement as soon as possible[healthfrom.com]

References

Article

  1. Saber A. Multiple splenic abscesses in a rather healthy woman: a case report. Cases J. 2009;2:7340.
  2. Tung CC, Chen FC, Lo CJ. Splenic abscess: an easily overlooked disease? Am Surg. 2006;72(4):322-325.
  3. Chiang IS, Lin TJ, Chiang IC, Tsai MS. Splenic abscesses: review of 29 cases. Kaohsiung J Med Sci. 2003;19(10):510-515.
  4. Lee W-S, Choi ST, Kim KK. Splenic Abscess: A Single Institution Study and Review of the Literature. Yonsei Medical Journal. 2011;52(2):288-292.
  5. Chang K-C, Chuah S-K, Changchien C-S, 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(3):460-464.
  6. Alvi AR, Kulsoom S, Shamsi G: Splenic abscess: outcome and prognostic factors. J Coll Physicians Surg Pak. 2008, 18: 740-743.
  7. Liu YH, Liu CP, Lee CM. Splenic abscesses at a tertiary medical center in Northern Taiwan. J Microbiol Immunol Infect. 2014;47(2):104-108.
  8. Ooi LL, Leong SS. Splenic abscesses from 1987 to 1995. Am J Surg. 1997;174:87e93.
  9. Brook I, Frazier EH. Microbiology of liver and spleen abscesses. J Med Microbiol. 1998;47:1075e80.
  10. Ng KK, Lee TY, Wan YL, et al. Splenic abscess: diagnosis and management. Hepatogastroenterology. 2002;49(44):567-571.

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Last updated: 2018-06-22 09:00