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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].

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]
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.[ecommons.aku.edu]
  • Patient had generalised malaise and had pain abdomen localized to left upper abdomen for last 2 days. There was no history of diarrhoea, vomiting, chronic fever, respiratory distress; or alteration in urinary and bowel habits.[oapublishinglondon.com]
  • 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]
Constitutional Symptom
  • It is noteworthy that this abscess was minimally symptomatic, with no fever or constitutional symptoms.[ncbi.nlm.nih.gov]
  • The finding of this imaging study was suggestive specially when correlated with clinical data including left upper abdominal pain, fever and other constitutional symptoms [ 5, 6, 8 ].[casesjournal.biomedcentral.com]
  • symptoms are fever, pain abdomen, anorexia, and weight loss. [9], [10], [11], [12] Tubercular splenic abscess may manifest with splenomegaly, fever of unknown origin, pain abdomen, and weight loss. [12], [13] In our case series, the predominant presenting[jacpjournal.org]
Pathologist
  • SANT presents a diagnostic challenge to clinicians, radiologists, as well as pathologists because of its extreme rarity. Therefore, it must be included as a differential diagnosis in cases with nonspecific pain or radiological splenic mass.[ncbi.nlm.nih.gov]
Splenomegaly
  • 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]
Massive Splenomegaly
  • PubMed Search: Plasmacytoma [title] spleen Localized mass (neoplasm) of plasma cells found in tissues other than bone Primary or secondary tumors are rare in spleen Primary tumors may cause massive splenomegaly and rupture The term plasmacytoma may sometimes[pathologyoutlines.com]
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]
Productive Cough
  • A 78-year-old woman presented to the acute medical unit with a productive cough, dyspnoea and decreased appetite of 4 days duration.[ncbi.nlm.nih.gov]
  • Case presentation A 78-year-old woman presented with productive cough, shortness of breath and decreased appetite for 4 days.[casereports.bmj.com]
  • Clinical symptoms were a productive cough, no thoracic pain and a moderately elevated body temperature of 38.1 C. Auscultation revealed vesicular breathing sounds.[military-medicine.com]
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]
  • 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]
Left Upper Quadrant Pain
  • When such patients have fever and left upper quadrant pain, splenic abscess should be considered.[ncbi.nlm.nih.gov]
  • upper-quadrant pain, a recent 9-kg weight loss, near-syncope, and subjective fevers, chills, and sweats.[consultant360.com]
Left Upper Quadrant Pain
  • When such patients have fever and left upper quadrant pain, splenic abscess should be considered.[ncbi.nlm.nih.gov]
  • upper-quadrant pain, a recent 9-kg weight loss, near-syncope, and subjective fevers, chills, and sweats.[consultant360.com]
Upper Abdominal Pain
  • He presented with left upper abdominal pain of three months' duration. The pain was dull, aching and non-radiating. There were no other associated features. Before this presentation, he was receiving oral steroids for a month.[ncbi.nlm.nih.gov]
  • Generally presenting with fever, leukocytosis, and left-sided upper abdominal pain in the setting of generalized sepsis, the majority had a distant source of bacteremia or an underlying defect in splenic architecture or function.[mayoclinic.pure.elsevier.com]
  • The clinical manifestations of splenic abscesses usually include left upper abdominal pain, fever, nausea, vomiting and anorexia may be also present in various combinations [ 5 ].[casesjournal.biomedcentral.com]
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]
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]
  • Case 2 A 35-year-old female obese patient underwent LSG. 75 days later, the patient was admitted to the hospital due to LUQ abdominal pain, left shoulder pain, and fever.[karger.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]
  • Case 2 A 35-year-old female obese patient underwent LSG. 75 days later, the patient was admitted to the hospital due to LUQ abdominal pain, left shoulder pain, and fever.[karger.com]
Altered Mental Status
  • 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]
  • Typically the radiographic findings are elevation of the left hemidiaphragm and left pleural effusion as shown in this case. However the ultrasound scan and CT scan are more reliable diagnostic tests as in this case.[ncbi.nlm.nih.gov]
  • 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]
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]
Enlargement of the Spleen
  • Scudder laid great stress upon the action of polymnia uvedalia in enlargement of the spleen, and other observers have confirmed his conclusions, especially upon that form induced by chronic malaria.[henriettes-herb.com]
Thrombocytosis
  • 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]
  • Two months later he developed recurrent thrombophlebitis and fatal thromboembolism associated with thrombocytosis.[annals.org]
  • 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]
  • In cases of splenectomy, thrombocytosis occurs in more than 50% of cases. A very high platelet count ( 1,000,000/μL) necessitates intervention to minimize the incidence of thrombotic complications.[emedicine.medscape.com]
Bartonella Henselae
  • 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]
  • PubMed Search: Bacillary angiomatosis [title] Rare vasculoproliferative disorder due to Bartonella henselae or Bartonella quintana Called peliosis hepatitis in liver and spleen Usually cutaneous angioma-like tumor, solitary or multiple Rare dissemination[pathologyoutlines.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]

Treatment

  • 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.[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]

Etiology

  • 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]
  • 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]
  • […] catheterization in the newborn. [20] A case of chronic splenic abscess occurring as the initial manifestation of pancreatic tail carcinoma has been reported. [21] Splenic abscess has been reported as a rare complication of sleeve gastrectomy. [22, 23] Epidemiology[emedicine.medscape.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]
Sex distribution
Age distribution

Pathophysiology

  • We could not find out the etiology and pathophysiologic mechanism of splenic abscess in our patient.[ijamhrjournal.org]
  • 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]
  • […] 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 stomach and pancreas can be affected in an analogous way. [8] Pathophysiology Splenic abscesses occur in a variety of clinical scenarios.[emedicine.medscape.com]

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]
  • 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]
  • The early switch to cefotaxime, initiated due to radiological findings initially interpreted as pneumonia, may have prevented a poor outcome, but on the other hand, this erroneous interpretation complicated the diagnosis.[archbronconeumol.org]

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: 2019-07-11 21:48