Left Upper Quadrant Pain and Pyrexia in a 50-Year-Old Man

Anusuya Mokashi, MD; Dhana Rekha Selvaraj, MD, MBBS; Chandrasekar Palaniswamy, MD; Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Klaus L. Irion, MD, PhD

Disclosures

December 09, 2016

Discussion

Sections of the CT scan show a low-density lesion within the spleen, with multiple areas of air density highly suggestive of a splenic abscess with gas-forming organisms. Splenic abscess is a rare clinical entity. A high index of suspicion is required for the diagnosis because the clinical presentation is often nonspecific. Prompt diagnosis and early management are essential because this disease is associated with a high mortality rate. Autopsy studies have suggested an incidence of 0.14% to 0.70%, with a slight predominance in males.[1,2] The estimated incidence in a clinical setting is 0.012% per 1000 hospital admissions per year. People of any age group can be affected.[3] The mortality rate is as high as 47% and, in untreated patients, it reaches 100%.[4]

Alcoholics, diabetics, and immunosuppressed individuals, including patients with AIDS, are at risk. Predisposing events to splenic abscess include splenic infarction (which can result from sickle cell anemia, leukemia, or therapeutic embolization) and splenic trauma related to the infection of devitalized tissue.[4] In this patient, in addition to the serologic tests noted above, screenings for lymphoma, immunoglobulin, and hydatid cysts were all negative. The etiology was thought to be secondary to the splenic trauma that the patient had recently suffered.

The route of infection for the development of a splenic abscess can be hematogenous, stemming from a distant focus, or it can be contiguous, spreading from the adjacent organs and peritoneal spaces. Infectious endocarditis is considered to be the most common source of infection, accounting for 10% to 20% of associated splenic abscesses.[5]

Other sources of infection include typhoid, malaria, urinary tract infection, osteomyelitis, otitis media, pneumonia, appendicitis, and pelvic infection. Infections in contiguous areas, such as pancreatitis , pancreatic adenocarcinoma, retroperitoneal or subphrenic abscesses, and diverticulitis, can extend to involve the spleen.

Polymicrobial flora is seen in 50% of cases. Bacterial splenic abscesses are most commonly caused by Staphylococcus, Streptococcus, Enterococci, Salmonella, Escherichia coli, Klebsiella, Proteus, and Pseudomonas.[4] Mycobacterial and Candida infections are usually encountered in immunocompromised patients. In endemic areas, Burkholderia pseudomallei is a common etiologic agent. Unifocal abscesses are usually related to bacterial infections, whereas miliary or mutifocal abscesses are usually related to fungal or mycobacterial infections.[6,7]

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