Management of splenic abscess in children by percutaneous drainage

Management of splenic abscess in children by percutaneous drainage

Journal of Pediatric Surgery (2006) 41, E53 – E56 www.elsevier.com/locate/jpedsurg Management of splenic abscess in children by percutaneous drainag...

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Journal of Pediatric Surgery (2006) 41, E53 – E56

www.elsevier.com/locate/jpedsurg

Management of splenic abscess in children by percutaneous drainage Roy Choudhury S*, Chadha Rajiv, Sonker Pitamber, Sharma Akshay, Singh Dharmendra Department of Pediatric Surgery, Lady Hardinge Medical College and Associated Kalawati Saran Children’s Hospital, New Delhi 110001, India Index words: Splenic abscess; Children

Abstract Background/Purpose: Isolated splenic abscesses are rare in pediatric patients. The recommended treatment in the literature has been in favor of splenectomy, although conservative treatment with splenic preservation is being increasingly reported. We report successful management of 4 pediatric patients with splenic abscess by needle aspirations and antibiotics. Materials and Methods: Four children (aged 7-11 years; male-female, 3:1) were admitted in our institution with history of high-grade fever with chills, anorexia, left hypochondrial pain, and splenomegaly. One child was a known case of thalassemia, and one had a history of typhoid fever. The others did not have any predisposing condition. Ultrasonography (USG) and computed tomographic scan of the abdomen showed a solitary abscess in the spleen in 2 patients and multiple abscesses in the other 2. Ultrasonography-guided needle aspiration in 3 cases revealed purulent fluid, which, on culture, grew Escherichia coli in 1 case, Salmonella paratyphi A in 1 case, but sterile in 1 case. Blood culture was sterile in all the cases, but Widal’s test was positive in 2 patients. Treatment protocol included USG-guided needle aspiration of pus along with intravenous ceftriaxone, metronidazole, and amikacin for 3 to 12 weeks. Results: All 4 patients showed a good response to conservative treatment. Serial USG showed gradual resolution of abscess, and none was subjected to splenectomy. Conclusion: Isolated splenic abscess in children can be successfully treated with needle aspirations and intravenous antibiotics, thereby avoiding splenectomy. D 2006 Elsevier Inc. All rights reserved.

Isolated splenic abscesses are rare in children [1-3] but carry a high mortality in nonrecognized and untreated cases [4,5]. Metastatic infection from other parts of the body is the most common etiology, although recently, an increasing number of cases are being recognized as being secondary to

4 Corresponding author. Tel.: +91 11 26494598. E-mail address: [email protected] (R. Choudhury S). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.10.085

immunocompromised state resulting from hematologic disorders, transplantation, AIDS, or cancer chemotherapy [6,7]. Staphylococcus, Streptococcus, Salmonella, and Escherichia are the usual organisms isolated, although Candida and atypical mycobacteria are common in immunocompromised children [6,8]. The clinical presentation includes fever, left upper abdominal pain, leukocytosis, leftsided pleural effusion, and splenomegaly [6]; however, fever and leukocytosis may be absent in immunocompromised

E54 children, thus causing delay in the diagnosis [5]. Combined ultrasonography (USG) and computed tomographic (CT) scan are useful imaging modalities for the diagnosis of splenic abscess [9-12]. The gold standard of treatment had been splenectomy with broad-spectrum antibiotic therapy [7,13-15]. However, an increasing number of patients, particularly children, is now being managed conservatively by aspirations, drainage, and antibiotics, thereby avoiding splenectomy [16,17]. In this article, we present the diagnosis and management of 4 cases of isolated splenic abscess in children.

1. Case reports 1.1. Case 1 A 9-year-old male child presented with history of highgrade fever with chills, abdominal pain, anorexia, and vomiting of 15 days’ duration. There was no history of trauma, jaundice, hemoglobinopathy, or other associated illness. On examination, the child was toxic and febrile. Abdominal examination revealed tender splenomegaly of 2 cm below the left costal margin. Laboratory investigation revealed hemoglobin level of 9 g/dL, total leukocyte count of 9500/mm3, and platelet count of 173 000/mm3. Liver and renal function tests were within normal limits, and blood culture did not grow any organism. Abdominal USG showed multiple hypoechoic lesions in the spleen consistent with the diagnosis of splenic abscess. Computed tomographic scan abdomen showed multiple splenic abscesses (Fig. 1). The patient was treated with intravenous ceftriaxone, amikacin, and metronidazole for 2 weeks. Ultrasoundguided needle aspiration yielded small amount of pus, which was sterile on culture. The progress was monitored with serial USG, which showed decreasing size of the abscess. At 6 months’ follow-up, the child was doing well and was disease-free.

R. Choudhury S et al.

1.2. Case 2 A 10 -year-old female child presented with history of fever with chills of 1 month’ duration. This was associated with abdominal pain, anorexia, and vomiting. She was a known case of seizure disorder and thalassemia with history of blood transfusions. On examination, there was pallor and tender splenomegaly of 5 cm below the costal margin. Laboratory investigation revealed hemoglobin level of 7.5 gm%; total leukocyte count ranging from 19 000 to 29 000/mm3 with 83% neutrophils, and platelet count of 618 000/mm3. The Widal’s test showed significantly high titer for typhoid fever. Liver and renal function tests were within normal limits, and HIV serology was negative. Chest radiograph showed left pleural effusion. Ultrasonography abdomen revealed a hypoechoic lesion in the spleen suggestive of splenic abscess. Computed tomographic scan showed a large hypodense lesion with air and fluid collection in the spleen with contained spread into the left subphrenic space and left pleural effusion with consolidation of the base of the left lung. A left intercostal drainage tube was inserted, which drained purulent fluid. Cytology of the pleural fluid showed large number of pus cells and gram-negative bacilli, which, on culture, grew Escherichia coli. Ultrasound-guided aspiration of the abscess yielded small amount of thick pus that also grew E coli on culture. The child was treated with intravenous ceftriaxone, amikacin, and metronidazole for 4 weeks before complete subsidence of fever. The abscess size was monitored with regular USG, which showed gradual resolution. The patient was doing well on follow-up up to 1 year.

1.3. Case 3 A 7-year-old male child presented with high-grade fever of 3 weeks’ duration associated with abdominal pain and poor appetite. There was no history of trauma, jaundice, or other associated illness. General physical examination was unremarkable except mild pallor. Abdominal examination revealed tenderness over the left hypochondrium. Investigations showed hemoglobin level of 9.5 gm%, total leukocyte count of 9600/mm3, and platelet count of 268 000/mm3. Liver and renal function tests were normal, and Widal’s serology was negative. Ultrasonography abdomen revealed splenomegaly with an anechoic lesion measuring 3.1  2.9  2 cm in the spleen consistent with splenic abscess. The patient was treated with intravenous ceftriaxone, amikacin, and metronidazole for 3 weeks before clinical improvement. Serial USG scan showed gradual resolution of the abscess. At 3 months’ follow-up, the patient was asymptomatic.

1.4. Case 4 Fig. 1 Computed tomographic scan of abdomen showing multiple splenic abscess (case 1).

An 8-year-old male child presented with history of fever for 15 days and left upper abdominal pain of 5 days’ duration. There was a history of typhoid fever 3 years ago.

Splenic abscess in children

Fig. 2 Ultrasonography of abdomen showing large splenic abscess (A) resolution of abscess after treatment (B) (case 4).

Abdominal examination showed tender splenomegaly of 4 cm below the left costal margin. Ultrasonography revealed multiple hypoechoic areas in the spleen, suggestive of splenic abscesses. Computed tomographic scan of the abdomen showed multiple splenic abscesses. Laboratory tests showed hemoglobin level of 7 gm%, total leukocyte count of 13 400/mm3, 62% segmental neutrophils, 30% lymphocytes, and platelet count of 356 000/mm3. The Widal’s serology was positive for typhoid fever, and blood culture was sterile. Ultrasound-guided needle aspiration revealed 5 mL hemorrhagic fluid with flakes of pus. Cytology of the aspirate showed numerous pus cells, and the culture grew Salmonella paratyphi A. The child was treated with intravenous ceftriaxone, amikacin, and metranidazole for 2 weeks and showed good clinical response. At 1 month’s follow-up, the child was asymptomatic and the abscesses had resolved on USG (Fig. 2).

2. Discussion Isolated abscesses of the spleen are a rarity in children but are being increasingly recognized in association with an

E55 immunocompromised state [8,18]. In large series and reviews that include both the adult and pediatric population, the etiologic factors recognized are metastatic infection from other sites in the body, such as bacterial endocarditis [1,15], secondary infection of splenic infarction such as hemoglobinopathies [19], trauma to the spleen, immunodeficiency state, and rarely contiguous infection by direct spread [6]. One of our cases was a thalassemic and one child had a history of typhoid fever, but the others did not have any predisposing factors. The common organisms isolated from culture of the abscess are staphylococci, streptococci, Salmonella, Escherichia, and enterococci [1,5,6]. However, mycobacteria such as Mycobacterium tuberculosis or M avium-intracellulare and fungi such as Candida and Aspergillus [6,8] are increasingly being reported in immunocompromised patients and those with AIDS or after chemotherapy [18]. Blood culture is reported to be positive in 48% cases [6], whereas abscess aspirate culture positivity varies from 73% [6] to 14 % [13] and is usually monomicrobial. Abscess aspirate culture was positive for E coli in one and S paratyphi A in another patient. The negative aspirate culture in 1 patient could be because of commencement of antibiotic therapy before obtaining the culture, which could also explain the negative blood culture in all our patients. The positive Widal’s test in 2 cases indicates infection by the Salmonella group. All our patients had the classic triad of symptoms that include fever with chills, left upper quadrant pain, and tender splenomegaly. [6] Leukocytosis is a frequent accompaniment [1,7]; however, it may be absent or even a decreased count may be seen in immunocompromised patients [8] and because of previous antibiotic therapy [20]. Two of our patients had leukocytosis, whereas the others had normal counts. Unexplained thrombocytosis has been reported in association with splenic abscess [21], which was noted in 3 of our patients. Solitary abscess is commoner (65%) than multiloculated (8%) and multiple abscesses (27%) [6]. Two of our cases had multiple abscesses, whereas the other 2 had solitary abscess with extrasplenic spread in 1 patient. Chest and abdominal x-ray may show nonspecific findings such as soft tissue mass in the left upper quadrant, displacement of gastric or colonic gas shadow, extra alimentary gas or air-fluid level in left hypochondrium, elevation of left hemidiaphragm, and left pleural effusion [20,22]. Ultrasonography has a diagnostic sensitivity up to 90% [9,10, 23,24], and CT scan is superior to USG with the reported sensitivity of 96% [6,12]. Ultrasonography was diagnostic in all our cases, which were further confirmed with CT scan. Other imaging modalities such as radionuclide scan, magnetic resonance imaging are currently unnecessary for making the diagnosis [6]. Splenectomy had been the gold standard of treatment for splenic abscess in the literature based mainly on adult patients [13,14]. Splenic preservation is important for the immunologic functions of the spleen in children [2]. Successful treatment of single and multiple splenic abscesses

E56 in children with antibiotic therapy alone have been reported [16,17]. Ultrasonography- or computed tomography – guided drainage has a reported success rate of more than 75% [3,25 -28]. Smith et al [8] suggested splenectomy for the treatment of splenic abscess in immunocompromised children and in patients with multiple splenic abscess because they feel it is difficult to eradicate the infection from the reticuloendothelial cells of the spleen, which are not well penetrated by systemic antibiotics [29]. However, others have recommended conservative treatment for such patients similar to the treatment of hepatic and renal abscess [2,16]. Because reports on splenic abscess in children consist of small number of patients, it is difficult to draw a conclusion regarding the correct approach to the management. In our opinion, conservative management should be the primary approach to the treatment of splenic abscess. This is especially so because salvage splenectomy after failure of conservative treatment has not been reported to increase mortality compared with splenectomy as initial therapy [6]. In conclusion, we have presented 4 children with isolated splenic abscess, single and multiple, being successfully managed with conservative treatment (aspiration and antibiotics), thereby avoiding splenectomy.

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