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

The classic triad described for splenic abscess consists of fever (>90% of cases), left upper quadrant pain (>39% of cases), and splenomegaly (<50% of cases). Any pain experienced by the patient can be referred to the left shoulder if the diaphragmatic pleura is involved (Kehr sign). Pleuritic chest pain aggravated by cough or forced expiration can be present (in approximately 15% of cases), as can costovertebral tenderness. Rales and dullness in the left lung base are seen in few patients.[4] Leukocytosis with a left shift is seen in most patients, except, potentially, in immunocompromised patients. Positive blood cultures support the diagnosis.

Imaging plays an important role in localizing the focus of infection, differentiating the abscess from other lesions, and guiding the treatment. Conventional radiography can be a good starting point, but a finding of abnormal soft tissue density with or without gas is a nonspecific finding. Chest radiograph findings are abnormal in 80% of patients; an elevated left hemidiaphragm, pleural effusion, or lower lobe atelectasis might be seen. An abnormal soft tissue density or gas pattern is identified in the left upper quadrant in up to 35% of patients. Plain radiographs of the abdomen might show abnormal soft tissue density in the left upper quadrant and the presence of gas; however, these findings are often nonspecific (as stated above).[4]

Ultrasonography is the preferred initial imaging modality because it has good sensitivity, is easily available, is noninvasive, and is portable. The sonographic appearance of splenic abscesses includes unilocular, multilocular, hypoechoic, and anechoic lesions, which can contain septations and internal debris.[7] Color Doppler studies can help differentiate abscesses from neoplasms because abscesses typically have an avascular appearance.[8] CT scanning is considered more accurate for making a definitive diagnosis. On CT scans, the lesions appear hypodense and they show peripheral enhancement on intravenous contrast, which helps differentiate abscesses from cysts and hematomas.[9] Infection with Candida can give rise to "bull's eye" lesions, which are seen as hypoattenuating foci with central cores of hyperattenuation.[7]

The lesions are hypointense on T1-weighted MRI and isointense or hyperintense on T2-weighted images. Radionuclide-labeled studies using technetium-99m-labeled leukocytes can be used to differentiate the foci of acute infection from splenic infarcts; infections will show increased uptake, whereas infarcts are seen as focal defects.[10] The presence of a gas or fluid level in the lesion (in the absence of previous interventions or biopsy procedures) is considered pathognomonic of pyogenic abscess[7]; however, few case reports demonstrate the presence of gas caused by a nonsuppurative infarction of the spleen. The main feature differentiating a nonsuppurative infarction from an infection is the presence of gas in the arteries, which gives rise to linear air collections seen on CT scans.[11,12]

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