Systemic infection and splenic abscess
Aaron R. Belknap, MD, and Joseph Guileyardo, MD
Splenic abscess is a rare complication of systemic infection, sometimes
associated with infective endocarditis. Due to its rarity and nonspecific
symptoms, diagnosis is difficult. Antibiotic therapy alone is usually unsuccessful, and definitive treatment requires splenectomy, although percutaneous ultrasound-guided drainage has been successful in some patients.
Abdominal computed tomography scans and ultrasound evaluation are
usually diagnostic. We present two patients with treatment-resistant
sepsis who were found at autopsy to have splenic abscess.
S
plenic abscess is a rare complication of systemic infection, but when present may be associated with bacterial
endocarditis (1). Considering the spleen’s function of filtering blood, splenic abscess is surprisingly uncommon.
In 564 patients with infective endocarditis, only 5% developed
a splenic abscess (2). Due to its nonspecific signs and symptoms,
the diagnosis is easily missed or delayed. Successful treatment
usually requires surgical resection of the infected spleen (3).
Computed tomography scans and ultrasound usually identify
the splenic lesion. We present two patients with treatmentresistant systemic infections who were found at autopsy to have
splenic abscesses.
CASE REPORTS
Case 1
A 57-year-old woman with chronic lower back pain presented to an outside hospital with a 1-month history of nausea,
vomiting, and fatigue. Three to four days prior to admission, she
had been bitten by her dog. The outside hospital diagnosed septic shock, and she was transferred to Baylor University Medical
Center at Dallas. Blood cultures were positive for Streptococcus
anginosus.
She was given broad-spectrum antibiotics, vancomycin, meropenem, clindamycin, and eventually continuous penicillin
infusions. However, she continued to deteriorate with intermittent fevers, distal ischemic necrosis of the hands and feet, and
large cutaneous bullae. Clinically, she developed disseminated
intravascular coagulopathy and suspected toxic shock. Chest
x-ray suggested an acute respiratory distress syndrome. Despite
therapy, she did not improve, was transitioned to comfort care,
and died.
Proc (Bayl Univ Med Cent) 2017;30(2):173–174
Autopsy found a puncture wound consistent with a dog bite
on the left index finger. Ischemic necrosis of the distal extremities and acute lung injury were also confirmed. An unexpected
finding was a subcapsular splenic abscess measuring 3.5 cm
in greatest dimension with associated organizing splenic vein
thrombosis. She died from multisystem organ failure due to a
systemic inflammatory response syndrome associated with septic
shock, likely due to Streptococcus anginosus.
Case 2
A 52-year-old man with severe obesity, sleep apnea, and
atrial fibrillation presented to an outside hospital for atrial ablation therapy. Following this procedure, he developed a bloody
pericardial effusion, pericarditis, and multiorganism bacteremia
including Gemella sp., Prevotella sp., Fusobacterium nucleatum,
anaerobic gram-positive cocci, and anaerobic gram-negative
coccobacilli. Culture of the pericardial effusion was positive
for Propionibacterium acnes. Cranial imaging demonstrated
multifocal acute and subacute hemorrhagic infarcts in addition to multiple cerebral abscesses. Following deterioration of
his condition, the patient was transferred to Baylor University
Medical Center at Dallas for a higher level of care.
Upon arrival, intensive antibiotic therapy including central
nervous system doses of vancomycin, ceftriaxone, metronidazole, and ceftazidime were given, but the source of the continuing bacteremia could not be identified, and the patient remained
febrile. A few days following transfer, the patient suffered myocardial infarction with troponin levels peaking >200 ng/mL,
but due to the cerebral hemorrhage, he was not a candidate
for anticoagulation. He was transitioned to comfort measures
and died.
An autopsy confirmed multifocal organizing cerebral
hemorrhages and abscesses, pericarditis, and an acute myocardial infarction. The autopsy also demonstrated multifocal splenic
abscesses, with the largest measuring 6.0 cm in greatest dimension. The patient died from complications of morbid obesity
From the Department of Pathology, Baylor University Medical Center at Dallas,
Texas.
Corresponding author: Aaron R. Belknap, MD, Department of Pathology, Baylor
University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246
(e-mail: [email protected]).
173
resulting in massive cardiomegaly and atrial fibrillation requiring
atrial ablation with subsequent infectious complications.
DISCUSSION
These patients both died from bacterial sepsis associated with
unrecognized splenic abscesses, and abdominal imaging, such
as computed tomography or ultrasound, was not performed
on either patient. The rarity of this complication, along with
the difficulty in diagnosis, requires a high index of suspicion
in patients with sepsis that is refractory to antibiotic therapy.
However, the classic triad of fever, leukocytosis, and left upper
quadrant abdominal pain is not present in many cases. The
most sensitive signs are fever (90%) and leukocytosis (88%);
however, these are obviously nonspecific (4). Furthermore, both
patients had multiple negative blood cultures after the initial
positive culture, but despite aggressive antibiotic therapy, neither improved. In general, patients with infective endocarditis
or other forms of severe bacterial sepsis with abdominal pain or
swelling or with prolonged fever despite appropriate antibiotic
therapy should be considered for abdominal imaging in search
of a splenic abscess (5).
After diagnosis of a splenic abscess, standard therapy has
included immediate splenectomy (2). However, recent studies
have found some success with percutaneous ultrasound-guided
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drainage, followed by splenectomy in patients who did not
improve, and the reported rates of successful drainage procedures ranged from 17% to 100% (4, 6, 7). Furthermore, some
of these patients had multiple splenic abscesses that were successfully treated by multiple separate drainage procedures (6).
However, in view of the dire consequences of inadequate therapy
for splenic abscess, further studies are needed to clarify which
patients may be safely managed without splenectomy.
1.
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3.
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Baylor University Medical Center Proceedings
Volume 30, Number 2