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Abscess of the spleen
The NetherlanA
JOul!tPJAL OF M E D ICINIZ Netherlands Journal of Medicine 48 (1996) 11-14
Brief report
Abscessof the spleen F.P.J. Peters a~*, M .M.H. Hochstenbag a, F.W.C. Van Der Ent b, F.L.G. Erdkamp a a Department of Internal Medicine, Maasland Hospital, Postbus 5500, 6130 M B Sittard, Netherlands b Department of Surgery, Maasland Hospital, Postbus 5500, 6130 MB, Sittard, Netherlands
Received 7 February 1995; revised 12 April 1995; accepted 13 April 1995
Abstract Two unusualcasesare presentedof splenic abscesses causedby metastaticinfection with different organisms. The patientswere treated with splenectomyand antibiotics. Keywords:
Spleen;abscess;tuberculosis;Streptococcus (Enterococcus) faecalis; splenectomy
1. Introduction Splenic abscessis a circumscribed collection of pus in the spleen. It is an uncommon finding and has been reported in 0.7% of various autopsy series. Tuberculosis of the spleen as a cause of splenic abscessis even rarer and only 3 cases are described in a recent article [5,6]. In untreated cases the mortality is up to 100% [1,2]. In recent years the population at risk for abscessdevelopment has greatly increased due to the improved survival rates of various patients using immunosuppresive agents [4]. We present 2 case histories of patients with splenic abscess with different aetiology. We reviewed the available literature and will discuss presentation, diagnosis and treatment options.
* Corresponding author: Brugstraat 12, 6129 CL, Urmond, Netherlands.
2.
A 16-year-old boy with a history of pneumonia at the age of 11 years was admitted to our hospital. At that time bronchoscopy and examination of a bronchial lavage revealed a negative ZiehlNeelsen and tuberculosis culture. The reaction of the purified protein derivate (PPD) test was interpreted as not being typically positive (< 5 mm). After a period of 5 years with no symptoms of pulmonary disease, the patient presented in February 1994 with a 6-month history of pain at his left hip and he was tired. There was no history of fever, cough, anorexia, weight loss or abdominal complaints. Roentgenography of the left hip area showed a cyst at the trochanter major. The cyst was excised by the orthopaedic surgeon. Pathological examination showed a granulomatous infection without a positive Ziehl-Neelsen or tuberculosis culture. At postoperative examination the patient appeared pale and there was a splenomegaly without other organomegaly or free
0300-2977/96/$15.00 0 1996 Elsevier Science B.V. All rights reserved SSDI 0300-2977(95)00045-3
Case report no. 1
12
F.P.J. Peters et al. /Netherlands
Journal of Medicine 48 f 1996) I I-14
mg, pyridoxine 20 mg, all once a day) was started (will be continued for 1.5 years after the splenectomy, the first 4 months with 4 agents followed by a combination of isoniazid and rifampicin). At the last follow-up, 5 months after splenectomy, the patient was doing well. 3. Case report no. 2
Fig. 1. Computerized tomography showing abscesses in the spleen (patient no. 1).
fluid in the abdomen. Further examination revealed no other abnormalities. The laboratory findings at that time were as follows: erythrocyte Sedimentation Rate (ESR) 12 mm after 1 h (O-10 mm after 1 h), haemoglobin concentration 7.3 mmol/l (8.7-11.2 mmol/l), leukocytes, differential cell count, thrombocytes, immunoglobulin A, G, M (quantitative), liver and kidney function test were normal. The PPD test and the sputum culture (Mycobacterium tuberculosis and standard microbiological test) were negative. A chest roentgenogram revealed no abnormalities. Ultrasound and computer tomography showed well-defined lesions in the spleen itself and around the region of the spleen (Fig. 1). A blind needle aspiration of the spleen was not conclusive (the amount of tissue was inappropiate for a proper diagnosis). Laparoscopic examination of the upper abdomen with aspiration of pus gave the diagnosis of splenic abscess. At that time the PPD test was negative. Subsequently at laparotomy, multiple hilar, splenic and pancreatic abscesseswere found and a splenectomy and partial pancreatectomy were performed. Bacteriological examination showed M. tuberculosis in the spleen and abscess fluid. The postoperative course was uneventful and antitubercular treatment (isoniazid 300 mg, ethambutol 1200 mg, rifampicin 600 mg, pyrazinamide 1500
A 50-year-old man who catheterized himself 1 year after surgery for an urethral stenosis presented to the hospital complaining of 1 day of melaena. One week before admission he had suffered from abdominal pain localized in the left upper quadrant of the abdomen. Deep breathing worsened the pain. There was no history of trauma or fever. He smoked 30 cigarettes and consumed a lot of alcohol daily ( > 2 litres of beer a day). On examination he appeared ill, pale, haemodynamically stable, distressed by pyrexia of 38°C and ankle oedema. There was no organomegaly. Rectal examination showed melaena. ESR was 55 mm after 1 h (O-10 mm/h), haemoglobin concentration 2.6 mmol/l (8.7-11.2 mmol/l), albumin concentration 21 g/l (35-51 g/l), creatinine concentration 294 pmol/l (45125 pmol/l) and urea concentration 28.2 mmol/l (3.0-7.0 mmol/l). The liver function tests were normal. Cultures of stools and urine were negative. No proteinuria was detected. Gastroscopy showed a oesophago-gastric erosion with a blood clot and treatment with omeprazol was started. The patient was transfused with 5 bags of packed cells. During, hospitalisation our patient developed fever up to 40°C. Haemocultures revealed Streptococcus
faecalis
(Enterococcus
faecalis)
species which was treated with amoxicillin. Because the complaints of pain in the left upper quadrant of the abdomen (worsened by deep breathing), a radionuclide liver-spleen scan was performed to exclude splenic pathology. This scan, however, showed an enlarged spleen with a defect in the upper part. Abdominal computer tomography revealed multiple defects in the upper part of the spleen (Fig. 2). Before surgical intervention he received pneumovax vaccine. A few days later laparoscopy and
F. P.J. Peters et al. /Netherlands Journal of Medicine 48 (1996) 11-l 4
Fig. 2. Computerized tomography showing abscessesin the spleen (patient no. 2).
aspiration of pus gave the diagnosis of splenic abscess,which was followed by splenectomy. Culture of aspirate from the removed spleen yielded Streptococcus faecalis (Enterococcus faecalis). The
antibiotics (amoxicillin) were given till 1 week after splenectomy. The postoperative course was uncomplicated. One month later he appeared well and to date no septic periods have recurred.
4. Discussion The twos cases presented both splenic abscessescauaed by metastatic infection with different organisms. The first patient probably had a primary pulmonary tuberculous infection a few years ago. The second patient developed spleen abscessesfrom recurrent urinary tract infections complicatecl by sepsis. There were negative urine cultures because recently our patient had been treated by the family doctor with antibiotics for a urinary tract infection (diagnosed by leukocyturia without a urine culture). The causes of splenic abscess can be divided into several groups: metastatic infection, contiguous infection, embolic non-infectious events causing ischaemia with subsequent superinfection (like sickle cell or haemolytic anaemia), trauma and due to an immunodeficient state [7,8].
13
There are no symptoms or signs pathognomonic for splenic abscesses.The incidence of symptoms is: fever (95%), abdominal pain (bO%), weakness (22%), chills (22%), left chest pain (17%), nausea and vomiting (16%) [8]. For the detection of splenic abscess,computer tomography has the highest sensitivity (96%), which is significantly superior to ultrasonography (76%), liver-spleen scanning (50%) and indium scanning (50%) [9]. Based on the organisms cultured from splenic abscesses aerobic organisms like streptococcus show an incidence of 76%, anaerobic organisms 5%, M. tuberculosis 0.8% [lo], Candida 0.8% and multiple organisms 11%. The incidence of sterile cultures is about 29% [6]. The treatment of choice for a splenic abscess is the combination of splenectomy and administration of antibiotics [6,9]. If it is technically impossible to perform a splenectomy, percutaneous drainage of the abscess is required. This treatment should only be reserved for young patients (because of its immunological consequenceswith risk of fatal pneumococcal infection) and patients who cannot tolerate an abdominal operation. The major drawback of percutaneous drainage of the spleen is the risk of residual infection. This method is unsuitable for multiple abscessesand abscesses due to disease in a contiguous organ. However, only solitary thick-walled abscesses should be treated by percutaneous drainage using a largesized catheter to garantee adequate drainage of the abscess [ll]. Because only two cases have been reported successfully treated with antibiotics alone, treatment solely with antibiotics is inappropriate [6]. The mortality in casesof splenic abscessis due to abscessesin other organs or complications like rupture of the spleen. Furthermore, mortality frequency is lower with early diagnosis and higher with increasing age (80% in the seventh decade vs. 22% in the second decade) [3,6]. As mentioned above, the incidence of a splenic abscessdue to tuberculosis is very rare. Tubercular abscessesof the spleen have been divided into splenic, splenic-hepatic, and spleno-hepatoglandular. The treatment of choice for tubercular
14
F.P.J. Peters et al. /Netherlands
splenic abscess like other splenic abscesses is splenectomy. The reason for the negative PPD reaction of patient no. 1 is the high level of antigeneity of the spleen by M. tuberculosis. A possible explanation may be that the T-cells (against M. tuberculosis) migrates towards the large pool of antigens in and around the spleen and will not give an intracutaneous reaction. Another possible explanation is that patient no. 1 cannot make the right T-cell population (against M. tuberculosis) resulting in a negative PPD test. Because only 3 cases have been reported in recent years, the role of postoperative antitubercular therapy is not clear. However, if lymph node involvement is suspected or proven, it may be a necessary adjunct [5,8]. In conclusion, splenic abscessesmay have an atypical clinical presentation and fever is not obligatory, as shown by our first patient. The treatment of choice is splenectomy whether or not followed by anti-infectious agents. References [l] Pickleman JR, Paloym E, Block GE. The surgical significance of splenic abscess. Surgery 1970;68:287-293.
Journal of Medicine 4X (1996) I I-14
[Z] Simson JNL. Solitary abscess of the spleen. Br .l Surg 1980;67:106-110. [3] Linos AL. Nagorney DM, McIIrath DC. Splenic abscess -the importance of early diagnosis. Mayo Clin Proc 1983;58:261-264. [4] Salame J, Mojddehian N, Kleiren P, et al. Atraumatic splenic rupture in the course of a pneumonia with streptococcus pneumoniae. Case report and literature review. Acta Chir Belg 1993;93:49-53. [5] AI-Salem AH. Mallapa KK, Qaisaruddin S. Tuberculous abscess of the spleen. Trop Geogr Med 1993;45(6):304307. [6] Gadacz TR. Splenic abscess. World J Surg 1985;9:410415. [7] Cavenagh D, Joseph AEA, Dilly S, Bevan DH. Splenic sepsis in sickle cell disease. Br J Haematol 1994;86:187189. [8] Agarwala S, Bhatnagar V, Mitra DK, Gupta AK, Berry M. Primary tubercular abscess of the spleen. J Pediatr Surg 1992;27(12):1580-1581. [9] 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. [lo] Wolff MJ, Bitran J, Rebeca G, Levy I, Levy IL. Splenic abscesses due to Mycobacterium tuberculosis in patients with AIDS. Rev Infect Dis 1991;13:373-375. [ill Akoh JA, Auld CD. Splenic abscess: Is conservation applicable? Br J Clin Pratt 1992:46(4):274-275.
JOul!tPJAL OF M E D ICINIZ Netherlands Journal of Medicine 48 (1996) 11-14
Brief report
Abscessof the spleen F.P.J. Peters a~*, M .M.H. Hochstenbag a, F.W.C. Van Der Ent b, F.L.G. Erdkamp a a Department of Internal Medicine, Maasland Hospital, Postbus 5500, 6130 M B Sittard, Netherlands b Department of Surgery, Maasland Hospital, Postbus 5500, 6130 MB, Sittard, Netherlands
Received 7 February 1995; revised 12 April 1995; accepted 13 April 1995
Abstract Two unusualcasesare presentedof splenic abscesses causedby metastaticinfection with different organisms. The patientswere treated with splenectomyand antibiotics. Keywords:
Spleen;abscess;tuberculosis;Streptococcus (Enterococcus) faecalis; splenectomy
1. Introduction Splenic abscessis a circumscribed collection of pus in the spleen. It is an uncommon finding and has been reported in 0.7% of various autopsy series. Tuberculosis of the spleen as a cause of splenic abscessis even rarer and only 3 cases are described in a recent article [5,6]. In untreated cases the mortality is up to 100% [1,2]. In recent years the population at risk for abscessdevelopment has greatly increased due to the improved survival rates of various patients using immunosuppresive agents [4]. We present 2 case histories of patients with splenic abscess with different aetiology. We reviewed the available literature and will discuss presentation, diagnosis and treatment options.
* Corresponding author: Brugstraat 12, 6129 CL, Urmond, Netherlands.
2.
A 16-year-old boy with a history of pneumonia at the age of 11 years was admitted to our hospital. At that time bronchoscopy and examination of a bronchial lavage revealed a negative ZiehlNeelsen and tuberculosis culture. The reaction of the purified protein derivate (PPD) test was interpreted as not being typically positive (< 5 mm). After a period of 5 years with no symptoms of pulmonary disease, the patient presented in February 1994 with a 6-month history of pain at his left hip and he was tired. There was no history of fever, cough, anorexia, weight loss or abdominal complaints. Roentgenography of the left hip area showed a cyst at the trochanter major. The cyst was excised by the orthopaedic surgeon. Pathological examination showed a granulomatous infection without a positive Ziehl-Neelsen or tuberculosis culture. At postoperative examination the patient appeared pale and there was a splenomegaly without other organomegaly or free
0300-2977/96/$15.00 0 1996 Elsevier Science B.V. All rights reserved SSDI 0300-2977(95)00045-3
Case report no. 1
12
F.P.J. Peters et al. /Netherlands
Journal of Medicine 48 f 1996) I I-14
mg, pyridoxine 20 mg, all once a day) was started (will be continued for 1.5 years after the splenectomy, the first 4 months with 4 agents followed by a combination of isoniazid and rifampicin). At the last follow-up, 5 months after splenectomy, the patient was doing well. 3. Case report no. 2
Fig. 1. Computerized tomography showing abscesses in the spleen (patient no. 1).
fluid in the abdomen. Further examination revealed no other abnormalities. The laboratory findings at that time were as follows: erythrocyte Sedimentation Rate (ESR) 12 mm after 1 h (O-10 mm after 1 h), haemoglobin concentration 7.3 mmol/l (8.7-11.2 mmol/l), leukocytes, differential cell count, thrombocytes, immunoglobulin A, G, M (quantitative), liver and kidney function test were normal. The PPD test and the sputum culture (Mycobacterium tuberculosis and standard microbiological test) were negative. A chest roentgenogram revealed no abnormalities. Ultrasound and computer tomography showed well-defined lesions in the spleen itself and around the region of the spleen (Fig. 1). A blind needle aspiration of the spleen was not conclusive (the amount of tissue was inappropiate for a proper diagnosis). Laparoscopic examination of the upper abdomen with aspiration of pus gave the diagnosis of splenic abscess. At that time the PPD test was negative. Subsequently at laparotomy, multiple hilar, splenic and pancreatic abscesseswere found and a splenectomy and partial pancreatectomy were performed. Bacteriological examination showed M. tuberculosis in the spleen and abscess fluid. The postoperative course was uneventful and antitubercular treatment (isoniazid 300 mg, ethambutol 1200 mg, rifampicin 600 mg, pyrazinamide 1500
A 50-year-old man who catheterized himself 1 year after surgery for an urethral stenosis presented to the hospital complaining of 1 day of melaena. One week before admission he had suffered from abdominal pain localized in the left upper quadrant of the abdomen. Deep breathing worsened the pain. There was no history of trauma or fever. He smoked 30 cigarettes and consumed a lot of alcohol daily ( > 2 litres of beer a day). On examination he appeared ill, pale, haemodynamically stable, distressed by pyrexia of 38°C and ankle oedema. There was no organomegaly. Rectal examination showed melaena. ESR was 55 mm after 1 h (O-10 mm/h), haemoglobin concentration 2.6 mmol/l (8.7-11.2 mmol/l), albumin concentration 21 g/l (35-51 g/l), creatinine concentration 294 pmol/l (45125 pmol/l) and urea concentration 28.2 mmol/l (3.0-7.0 mmol/l). The liver function tests were normal. Cultures of stools and urine were negative. No proteinuria was detected. Gastroscopy showed a oesophago-gastric erosion with a blood clot and treatment with omeprazol was started. The patient was transfused with 5 bags of packed cells. During, hospitalisation our patient developed fever up to 40°C. Haemocultures revealed Streptococcus
faecalis
(Enterococcus
faecalis)
species which was treated with amoxicillin. Because the complaints of pain in the left upper quadrant of the abdomen (worsened by deep breathing), a radionuclide liver-spleen scan was performed to exclude splenic pathology. This scan, however, showed an enlarged spleen with a defect in the upper part. Abdominal computer tomography revealed multiple defects in the upper part of the spleen (Fig. 2). Before surgical intervention he received pneumovax vaccine. A few days later laparoscopy and
F. P.J. Peters et al. /Netherlands Journal of Medicine 48 (1996) 11-l 4
Fig. 2. Computerized tomography showing abscessesin the spleen (patient no. 2).
aspiration of pus gave the diagnosis of splenic abscess,which was followed by splenectomy. Culture of aspirate from the removed spleen yielded Streptococcus faecalis (Enterococcus faecalis). The
antibiotics (amoxicillin) were given till 1 week after splenectomy. The postoperative course was uncomplicated. One month later he appeared well and to date no septic periods have recurred.
4. Discussion The twos cases presented both splenic abscessescauaed by metastatic infection with different organisms. The first patient probably had a primary pulmonary tuberculous infection a few years ago. The second patient developed spleen abscessesfrom recurrent urinary tract infections complicatecl by sepsis. There were negative urine cultures because recently our patient had been treated by the family doctor with antibiotics for a urinary tract infection (diagnosed by leukocyturia without a urine culture). The causes of splenic abscess can be divided into several groups: metastatic infection, contiguous infection, embolic non-infectious events causing ischaemia with subsequent superinfection (like sickle cell or haemolytic anaemia), trauma and due to an immunodeficient state [7,8].
13
There are no symptoms or signs pathognomonic for splenic abscesses.The incidence of symptoms is: fever (95%), abdominal pain (bO%), weakness (22%), chills (22%), left chest pain (17%), nausea and vomiting (16%) [8]. For the detection of splenic abscess,computer tomography has the highest sensitivity (96%), which is significantly superior to ultrasonography (76%), liver-spleen scanning (50%) and indium scanning (50%) [9]. Based on the organisms cultured from splenic abscesses aerobic organisms like streptococcus show an incidence of 76%, anaerobic organisms 5%, M. tuberculosis 0.8% [lo], Candida 0.8% and multiple organisms 11%. The incidence of sterile cultures is about 29% [6]. The treatment of choice for a splenic abscess is the combination of splenectomy and administration of antibiotics [6,9]. If it is technically impossible to perform a splenectomy, percutaneous drainage of the abscess is required. This treatment should only be reserved for young patients (because of its immunological consequenceswith risk of fatal pneumococcal infection) and patients who cannot tolerate an abdominal operation. The major drawback of percutaneous drainage of the spleen is the risk of residual infection. This method is unsuitable for multiple abscessesand abscesses due to disease in a contiguous organ. However, only solitary thick-walled abscesses should be treated by percutaneous drainage using a largesized catheter to garantee adequate drainage of the abscess [ll]. Because only two cases have been reported successfully treated with antibiotics alone, treatment solely with antibiotics is inappropriate [6]. The mortality in casesof splenic abscessis due to abscessesin other organs or complications like rupture of the spleen. Furthermore, mortality frequency is lower with early diagnosis and higher with increasing age (80% in the seventh decade vs. 22% in the second decade) [3,6]. As mentioned above, the incidence of a splenic abscessdue to tuberculosis is very rare. Tubercular abscessesof the spleen have been divided into splenic, splenic-hepatic, and spleno-hepatoglandular. The treatment of choice for tubercular
14
F.P.J. Peters et al. /Netherlands
splenic abscess like other splenic abscesses is splenectomy. The reason for the negative PPD reaction of patient no. 1 is the high level of antigeneity of the spleen by M. tuberculosis. A possible explanation may be that the T-cells (against M. tuberculosis) migrates towards the large pool of antigens in and around the spleen and will not give an intracutaneous reaction. Another possible explanation is that patient no. 1 cannot make the right T-cell population (against M. tuberculosis) resulting in a negative PPD test. Because only 3 cases have been reported in recent years, the role of postoperative antitubercular therapy is not clear. However, if lymph node involvement is suspected or proven, it may be a necessary adjunct [5,8]. In conclusion, splenic abscessesmay have an atypical clinical presentation and fever is not obligatory, as shown by our first patient. The treatment of choice is splenectomy whether or not followed by anti-infectious agents. References [l] Pickleman JR, Paloym E, Block GE. The surgical significance of splenic abscess. Surgery 1970;68:287-293.
Journal of Medicine 4X (1996) I I-14
[Z] Simson JNL. Solitary abscess of the spleen. Br .l Surg 1980;67:106-110. [3] Linos AL. Nagorney DM, McIIrath DC. Splenic abscess -the importance of early diagnosis. Mayo Clin Proc 1983;58:261-264. [4] Salame J, Mojddehian N, Kleiren P, et al. Atraumatic splenic rupture in the course of a pneumonia with streptococcus pneumoniae. Case report and literature review. Acta Chir Belg 1993;93:49-53. [5] AI-Salem AH. Mallapa KK, Qaisaruddin S. Tuberculous abscess of the spleen. Trop Geogr Med 1993;45(6):304307. [6] Gadacz TR. Splenic abscess. World J Surg 1985;9:410415. [7] Cavenagh D, Joseph AEA, Dilly S, Bevan DH. Splenic sepsis in sickle cell disease. Br J Haematol 1994;86:187189. [8] Agarwala S, Bhatnagar V, Mitra DK, Gupta AK, Berry M. Primary tubercular abscess of the spleen. J Pediatr Surg 1992;27(12):1580-1581. [9] 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. [lo] Wolff MJ, Bitran J, Rebeca G, Levy I, Levy IL. Splenic abscesses due to Mycobacterium tuberculosis in patients with AIDS. Rev Infect Dis 1991;13:373-375. [ill Akoh JA, Auld CD. Splenic abscess: Is conservation applicable? Br J Clin Pratt 1992:46(4):274-275.