Splenic abscesses in the new millenium - a systematic review

BACKGROUND

Isolated splenic abscesses are rare, but increasingly reported with newer organisms and changes in mechanisms involved. We conducted a comparative review of publications from 1900-1977, 1977-1986, 1987-1995, and 1996-2022.

METHODS

A systematic search in Embase and PubMed resulted in 522 publications (1111 cases). Data was tabulated, analysed, and compared.

RESULTS

Patient demographics and symptoms remain unchanged although more Asian patients were reported. Metastatic infections remain the main cause, but COVID-19-linked and iatrogenic causes post bariatric surgery and splenic artery embolization are increasingly reported. Aerobic organisms remain the commonest (68%), with a variety of exotic organisms reported. Splenectomy remains the definitive treatment, although antibiotics only and percutaneous aspiration/catheter-drainage are increasingly used with reasonable outcomes, with salvage splenectomy for therapeutic failures not having significantly higher mortality than upfront splenectomy.

CONCLUSIONS

Isolated splenic abscesses continue to be uncommon, with diagnosis requiring a high degree of suspicion. Non-surgical options for treatment can sometimes be definitive.

Synchronous Splenic and Intracerebral Abscesses in a Child

ABSTRACT

Splenic abscess is a life-threatening condition, which is very rare in children. There is usually an infective focus or pre-disposing factors such as immunodeficiencies towards developing splenic abscesses. Only one case of splenic abscess with brain abscesses in an adult has been reported in the English literature. We, therefore, report a case of an 11-year-old boy who was otherwise healthy, but presented with fever and weight loss for 2 months, right upper abdominal pain, vomiting, hypochondrial tenderness for 1 week and later on developed a left hemiplegia and right facioparesis 2 days before presentation. Diagnosis of splenic abscess and right intracerebral abscesses was confirmed with abdominopelvic ultrasound scan and abdominal and cranial computerised tomographic scans. He subsequently had percutaneous ultrasound-guided drainage of the splenic abscess which was not successful necessitating splenectomy with aggressive antibiotics treatment to which the patient responded with resolution of the brain abscesses and recovery of power in affected limbs. This report aimed to highlight the need for increased suspicion of splenic abscesses in children who are apparently immunocompetent and to add to the knowledge of management of this rare condition in children. We conclude that splenic abscess with intracerebral abscess is a rare but life-threatening condition which is amenable to treatment with drainage of abscess and aggressive guided antimicrobial therapy.

Splenic Abscesses in the Pediatric Population: A Literature Review of an Uncommon Entity

Splenic abscess in the pediatric population is a rare but serious condition. Its incidence is reported to be between 0.05% and 0.7%. Splenic abscess is an infectious suppurative process with a discernible macroscopic filling defect in the subcapsular space or spleen parenchyma. Causes include bacterial infection through the hematogenous route or from locoregional spread such as the gastrointestinal tract, septic emboli, trauma, sickle cell anemia, and malarial infestation. Diagnosis is often delayed due to non-specific signs and symptoms. Symptoms include fever, abdominal pain, and palpable left upper abdominal swelling. Ultrasound and cross-sectional imaging such as CT scans are useful for the diagnosis of splenic abscess but contrast-enhanced CT scans are considered the gold standard because of their high sensitivity and specificity. Treatment options range from antimicrobial therapy, percutaneous drainage, and aspiration to surgical interventions such as splenectomy. As it has a high mortality rate, prompt diagnosis and appropriate treatment are essential for optimal outcomes.

[Diagnostics and treatment of splenic abscesses]

A splenic abscess is a rare disease found in less than 1% of all autopsy studies. Several different diseases are associated as a predisposing factor, such as septic bacteremia due to endocarditis or diverticulitis, previous splenic trauma, immunosuppressive medication or diseases. The reported mortality in the literature is up to 24.5% in correctly diagnosed and treated cases. The diagnostic work-up primarily comprises sonography and computed tomography as well as a percutaneous puncture for determination of the pathogen. In most cases, a percutaneous interventional drainage treatment is sufficient and a splenectomy is necessary only in refractory cases.

Splenic abscess due to non-operative management of splenic injury: a case report

BACKGROUND

Splenic abscess is a rare disease, with incidence of 0.2-0.7% in previous studies. It often appears with left upper quadrant abdominal pain, fever, chills. Splenic abscess often happens because of hematogenous spreading of infections, endocarditis, angioembolization and some other rare reasons. Treatment relies on one of these two methods: percutaneous drainage or surgery.

CASE PRESENTATION

A 68-year-old diabetic Asian female (Asian woman) presented with generalized abdominal pain, low blood pressure, tachycardia, fever, lethargy and elevated level of blood sugar. She had history of conservative therapy in intensive care unit due to blunt abdominal trauma and splenic injury. She had a huge splenic abscess in ultrasonography and computed tomography scan so she went under splenectomy. Our patient had a splenic abscess without performing any intervention like angioembolization.

CONCLUSION

Immune compromised patients who are selected for nonoperative management after splenic injury need close follow up and evaluating about abscess formation for at least 2 weeks. Early diagnosis and treatment with two methods including percutaneous drainage or splenectomy should be considered and it depends on patient's risk factors, vital signs, general conditions and presence or absence of sepsis.

Case report: a case of multiple splenic abscesses in a child and literature review

Splenic abscesses in children are very rare, and multiple splenic abscesses are rarer. These lesions are difficult to diagnose quickly because of their low incidence and the low specificity of the associated clinical and imaging findings. The treatment of splenic abscesses includes conservative treatment, percutaneous drainage, and splenectomy, but the selection criteria for treatment are still unclear. We present a case of a 13-year-old girl with multiple splenic abscesses. Her blood culture report was negative. We eventually confirmed the diagnosis by enhanced magnetic resonance imaging (MRI). The patient underwent a successful laparoscopic total splenectomy, and her symptoms were resolved thereafter.

Evaluation of the Diagnostic Performance of mNGS in Detecting Intra-Abdominal Infections of the Emergency Department Patients

Purpose

Intra-abdominal infections (IAI) are gradually becoming common in the emergency department, though the incidence is low and the prognosis is fair, as the symptoms are similar to other intra-abdominal diseases, rapid and accurate diagnosis of the causative agents is essential for clinical management. This study aimed to evaluate the diagnostic performance of metagenomic next-generation sequencing (mNGS) in detecting IAI in the emergency department.

Patients and Methods

This was a retrospective, single-centered study including patients admitted to the emergency department from January 1st, 2021 to August 31st, 2022 with diagnosis of IAI. The comparison between mNGS and microbial culture using paracentesis fluid samples was performed to evaluate the diagnostic performance of mNGS for IAI. Meanwhile, paracentesis fluid and peripheral blood mNGS were compared to explore the sample specificity. Further, the microbial community structure of the patients with pyogenic liver abscesses (PLA) was analyzed.

Results

Thirty-four IAI patients including 23 with pyogenic liver abscesses (PLA), 3 with parapancreatic abscesses, and 8 with other IAI were included in this study. Compared with the conventional microbial culture of paracentesis fluid, mNGS using paracentesis fluid detected more positive cases of IAI (93.75% vs 81.25%), and identified more species of pathogens, especially in obligate anaerobes and viral pathogens. Peripheral blood mNGS presented a relatively high consistency with the paracentesis fluid mNGS (91% mutual positive). The microbial community structure of PLA patients with diabetes is less diverse than that of those without diabetes. Patients with diabetes are at high risk of PLA caused by Klebsiella pneumonia.

Conclusion

mNGS has advantages in detecting IAI in the emergency department, and peripheral blood mNGS can be a non-invasive choice for early diagnosis.

Splenic Abscess in an Adolescent due to Salmonella enterica Conservatively Treated with Ultrasound-Guided Fine-Needle Aspiration

Background

Splenic abscesses are rare and potentially fatal. Diagnosis is often delayed due to vague symptoms, and laboratory findings are varying and often nonspecific. Ultrasound and computed tomography have a high sensitivity in detecting splenic abscesses. Splenectomy was previously considered the gold standard for treatment, but in recent years, a shift has been seen towards a more conservative approach, i.e., ultrasound-guided aspiration or drainage in combination with adequate antibiotics in selected cases. Case Report. A previously healthy adolescent complained of left-sided chest pain, pain in the left clavicular region for three weeks, and recent fever. Ultrasound and computed tomography demonstrated an intrasplenic abscess. The patient was successfully treated with two percutaneous fine-needle punctures and adequate antibiotics for six weeks. Salmonella enterica serotype Poona was grown from the aspirate. At one-year follow-up, the patient remained healthy without signs of recurrence.

Conclusion

The present case report demonstrates that ultrasound-guided aspiration and subsequent treatment with antibiotics may be an effective alternative to splenectomy in patients with a splenic abscess.

Splenic Abscesses in Endocarditis: A Rare Disease with High Mortality. The Experience of a Heart Institute in Brazil

INTRODUCTION

Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition.

METHODS

Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed.

RESULTS

Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%.

CONCLUSION

Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.

Splenectomy versus Imaging-Guided Percutaneous Drainage for Splenic Abscess: A Systematic Review and Meta-Analysis

Background: Splenic abscess (SA) is a rare, life-threatening illness that is generally treated with splenectomy. However, this is associated with high mortality and morbidity. Recently, percutaneous drainage (PD) has emerged as an alternative therapy in select patients. In this study, we compare mortality and complications in patients with SA treated with splenectomy versus PD. Patients and Methods: A systematic literature search of 13 databases and online search engines was conducted from 2019 to 2020. A bivariate generalized linear mixed model (BGLMM) was used to conduct a separate meta-analysis for both mortality and complications. We used the risk of bias in non-randomized studies of interventions (ROBINS-I) tool to evaluate risk of bias in non-randomized studies, and the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach for assessing quality of evidence and strength of recommendations. Results were presented according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Results: The review included 46 retrospective studies from 21 countries. For mortality rate, 27 studies compared splenectomy and PD whereas 10 used PD only and nine used splenectomy only. Data for major complications were available in 18 two-arm studies, seven single-arm studies with PD, and seven single-arm studies with splenectomy. Of a total of 589 patients, 288 were treated with splenectomy and 301 underwent PD. Mortality rate was 12% (95% confidence interval [CI], 8%-17%) in patients undergoing splenectomy compared with 8% (95% CI, 4%-13%) with PD. Complication rates were 26% (95% CI, 16%-37%) in the splenectomy group compared with 10% (95% CI, 4%-17%) in the PD group. Conclusions: Percutaneous drainage s associated with a trend toward lower complications and mortality rates compared with splenectomy in the treatment of SA, however, these findings were not statistically significant. Because of the heterogeneity of the data, further prospective studies are needed to draw definitive conclusions.

Splenic Abscess in the New Millennium: A Descriptive, Retrospective Case Series

Background

Splenic abscess is a rare infection often resulting from hematogenous spread. Immunocompromised states are commonly comorbid, and the microbiology is heterogeneous.

Methods

We conducted a retrospective review of 33 cases identified by convenience sampling. Cases were treated in our institution’s hospital system between May 2012 and February 2021 and classified as proven or probable based on predetermined criteria.

Results

The median age was 57 years, and 58% were men. Common underlying diseases included diabetes mellitus (30%), pancreatic disease (30%), and hematological malignancy (15%). The most common mechanism of pathogenesis was hematogenous spread (n = 13). Escherichia coli, enterococcal spp., and anaerobes were frequently implicated. One case was discovered at autopsy and excluded from subsequent analyses. The median duration of antimicrobial therapy (range) was 45 (5–525) days, and the median length of index hospitalization was 20 days. Percutaneous drainage by interventional radiology was common (17 of 32; 53%), and 6 patients underwent splenectomy. Treatment success was achieved in 14 of 32 cases (44%), with clinical stability in 3 of 32 cases (9%). Failures occurred in 13 of 32 (41%) cases, 2 of whom died from splenic abscesses. Two patients (2 of 32) were lost to follow-up.

Conclusions

To our knowledge, this is the largest North American series since the turn of the century and the first to distinguish between proven and probable cases. As reflected in our series, patients with splenic abscess may require prolonged hospitalizations and courses of antimicrobial therapy. Improvements in management are needed.

An Uncommon Case of Splenic Abscess with Gangrenous Gas Necrosis

Splenic abscess is a rare clinical entity with diagnostic challenges. Though rare, it is potentially a life-threatening clinical condition with high mortality reaching more than 70%. The common signs and symptoms include the triad of fever, left upper quadrant tenderness, and leukocytosis. Early diagnosis, however, can readily be made by the combination of clinical features, abdominal ultrasonography (USG), and computed tomography (CT). The management of splenic abscess includes medical therapy, CT-guided percutaneous aspiration, and splenectomy. We, hereby, present a rare case of splenic abscess with gangrenous gas necrosis, who underwent splenectomy.

Solitary 15 cm Splenic Abscess Successfully Treated with Percutaneous Drainage

Splenic abscesses are rare, but can be life-threatening. Antibiotics, percutaneous drainage and splenectomy are the usual treatment options. However, there is no ideal algorithm for choosing among these options. A man in his 60 s presented with 10 days of left upper quadrant pain and abdominal distension. Computed tomography (CT) scan of the abdomen revealed a splenic abscess measuring 15 cm in diameter. Transesophageal echocardiography confirmed the diagnosis of infectious endocarditis. Ultrasound-guided percutaneous drainage was performed and Streptococcus anginosus grew in cultures of both blood and intrasplenic fluid. The patient was treated with intravenous antibiotics and continuous drainage for 8 weeks. The abscess cavity nearly disappeared on follow-up CT scan. Percutaneous drainage should be considered for a solitary unilocular splenic abscess even if the abscess is large.

Splenic abscess as a possible sequela of COVID-19: a case series

Splenic abscess is an aggressive disease with a non-specific etiology and symptoms that are systemically detrimental. During the current COVID-19 pandemic, there has been a noted rise in the incidence of splenic abscesses. The aim of this article was to explore whether infection with the SARS-CoV-2 virus increases the risk of developing splenic abscesses. We reviewed three cases with SARS-CoV-2 infection who developed splenic abscess. The clinical characteristics, treatment course, management and outcome are reported. We perceived that hypercoagulability status, superimposing infections and immunosuppression were related to SARS-CoV-2 infection. These were common factors in these three observed cases of splenic abscess as a complication related to the new viral pandemic. SARS-CoV-2 infection might be a risk factor in development of splenic abscess. SIMILAR CASES PUBLISHED: To the best of our knowledge only one case similar to our case series was published.

WFUMB Position Paper-Incidental Findings, How to Manage: Spleen

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental Imaging Findings-The Role of Medical Ultrasound." IFs are less commonly encountered in the spleen than in many other abdominal organs but remain a frequent dilemma in clinical practice. A histological diagnosis is rarely necessary for patient management. Many IFs, such as secondary spleens and splenic cysts, are harmless and do not require any further investigation. The diagnosis of many other focal splenic lesions is, however, often problematic. The following overview is intended to illustrate a variety of incidentally detected spleen pathologies such as size variants, shape variants, secondary spleens, focal splenic lesions and splenic calcifications. It should aid the examiner in establishing the diagnosis. Moreover, it should help the ultrasound practitioner decide which pathologies need no further investigation, those requiring interval imaging and cases in which immediate further diagnostic procedures are required.

Splenic abscess after arterial embolization: a rare cause of acute abdomen

Splenic abscess is a rare disease and a diagnostic challenge for the medical team. Attributable to its high mortality, prompt diagnosis and treatment are essential. A high degree of clinical awareness is required in conjunction with aggressive treatment, as misleading symptoms may delay treatment and worsen the patient's prognosis. The management of splenic abscess is based on medical therapy, antibiotics and splenectomy or percutaneous drainage. We present the case of a 58-year-old patient presented with a splenic abscess after arterial embolization. He underwent surgery and completely recovered.

ACR Appropriateness Criteria® Radiologic Management of Infected Fluid Collections

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Management of Splenic Abscess after Splenic Arterial Embolization in Severe Acute Pancreatitis: A 5-Year Single-Center Experience

Objective

To describe the management and prognosis of splenic abscess after splenic arterial embolization in severe acute pancreatitis (SAP) patients.

Methods

This is a retrospective observational study. From August 2012 to August 2017, SAP patients with infected pancreatic necrosis (IPN) who underwent splenic arterial embolization after massive hemorrhage of the splenic artery were screened and those who developed splenic abscess were included for analysis. The demographic characteristics, etiology, treatment of splenic abscess, and clinical outcomes of these cases were collected and analyzed.

Results

A total of 18 patients with splenic abscess formed after splenic arterial embolization were included for data analysis. The median age of the 18 patients was 46 years. The etiologies included biliary AP, hypertriglyceridemic AP (HTG-AP), and other causes. Ten patients underwent minimally invasive percutaneous drainage only for splenic abscess while the other eight patients received splenectomy. One patient died due to uncontrolled infection and another patient died due to massive bleeding, and the remaining sixteen patients survived.

Conclusion

The incidence of splenic abscess was high in patients requiring splenic arterial embolization due to massive bleeding. Our data showed that most splenic abscess could be successfully managed with minimally invasive interventions, and traditional splenectomy should serve as a backup treatment.

Hypervirulent Klebsiella pneumoniae

Hypervirulent K. pneumoniae (hvKp) is an evolving pathotype that is more virulent than classical K. pneumoniae (cKp). hvKp usually infects individuals from the community, who are often healthy. Infections are more common in the Asian Pacific Rim but are occurring globally. hvKp infection frequently presents at multiple sites or subsequently metastatically spreads, often requiring source control. hvKp has an increased ability to cause central nervous system infection and endophthalmitis, which require rapid recognition and site-specific treatment. The genetic factors that confer hvKp's hypervirulent phenotype are present on a large virulence plasmid and perhaps integrative conjugal elements. Increased capsule production and aerobactin production are established hvKp-specific virulence factors. Similar to cKp, hvKp strains are becoming increasingly resistant to antimicrobials via acquisition of mobile elements carrying resistance determinants, and new hvKp strains emerge when extensively drug-resistant cKp strains acquire hvKp-specific virulence determinants, resulting in nosocomial infection. Presently, clinical laboratories are unable to differentiate cKp from hvKp, but recently, several biomarkers and quantitative siderophore production have been shown to accurately predict hvKp strains, which could lead to the development of a diagnostic test for use by clinical laboratories for optimal patient care and for use in epidemiologic surveillance and research studies.

Asymptomatic Splenic Cysts in an Immunocompromised Patient: Should They Be Investigated

Splenic abscess is a rare disease that generally occurs in immunocompromised patients. It is difficult to distinguish between splenic abscesses and cysts using imaging studies, especially if they are asymptomatic. A 50-year-old asymptomatic man who had received steroid therapy for underlying rheumatoid arthritis was referred to a university hospital due to presence of several splenic cysts, with the largest being 3.5 cm in diameter. Percutaneous aspiration was performed, and fluid analysis showed cysts infected by extended-spectrum, beta-lactamase-producing Escherichia coli. The patient was treated with ertapenem for four weeks, and the lesion disappeared on follow-up imaging studies. Splenic abscess should be included as a differential diagnosis of splenic cystic lesions in immunocompromised patients.

Splenic abscess due to fungal infection after kidney transplantation; a case report

Splenic abscess is one of the rare and potentially life-threatening complications after kidney transplantation. Splenic abscess generally occurs in patients who have immunodeficiency state. It becomes more important with the increased use of immunosuppressed drugs and organ transplantation. The clinical presentation of splenic abscess is insidious, often with constitutional symptoms. Left upper quadrant tenderness is an uncommon sign. Therefore, its diagnosis is difficult and requires a high degree of clinical suspicion. We report a case under renal transplantation with recurrent fungal infection in different organs with two episodes of fungemia who died after splenectomy.

Splenectomy for E. coli abscess: A case report with a difficult preoperative diagnosis and unclear pathogenesis

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Difficult diagnosis due to the paucity of symptoms and atypical radiological findings.

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Primary site of infection was not detected.

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Splenectomy is the best therapeutic choice in case of splenic abscess.

Introduction

Isolated splenic abscess is a rare clinical condition and remains a diagnostic dilemma. Clinical presentation is non-specific and the diagnosis is often delayed. Ultrasonography and CT scan are the gold standard. The treatment is still controversial: antibiotic therapy, percutaneous drainage (PCD) or splenectomy.

Case presentation

We present the clinical case of a patient, admitted to our Department because of abdominal pain, without fever. The preoperative radiological assesment showed three intrasplenic liquid collections, whose differential diagnosis was made between hematic collection and abscess. The treatment was splenectomy. The samples of collected liquid were positive for Escherichia Coli.

Conclusion

In case of splenic abscess, splenectomy is the best therapeutic choice. The other therapeutical options like antibiotic therapy and PCD, can be used only in particular cases, but without the same efficacy.

[Pneumoperitoneum due to splenic abscess: a diagnostic challenge. Case Report]

BACKGROUND

Splenic abscess is a rare clinic entity, its incidence has increased due to the rising number of clinical conditions involving immunosuppression. Endocarditis is the most frequent cause, and gram-positive aerobes are the main causal agents. Its clinical presentation is non-specific and delays diagnosis. Computed tomography scan is the method of choice, and the treatment is based on antibiotics and drainage, radiological or surgical, involving splenectomy in special cases that require it.

CLINICAL CASE

A 55-year-old man with abdominal pain and fever. The analysis revealed leukocytosis 14,000/mm3, prothrombin activity 53%, and metabolic acidosis. Computed tomography scan showed a peri-hepatic pneumoperitoneum, liquid fluid, and peri-splenic bubbles, and slight trabeculation of fat around the duodenal bulb with pneumoperitoneum in this area. Patient underwent a median laparotomy, finding a purulent peritonitis due to a ruptured abscess in the spleen, splenectomy was performed. Fluid culture showed polymorphonuclears, with no microorganisms identified. The patient progressed and was discharged on the 5th post-operative day.

CONCLUSIONS

Splenic abscess is an uncommon condition, in which the diagnosis is delayed and mortality, in untreated patients, is high. Its association with pneumoperitoneum may confuse the diagnosis towards viscera perforation. Thus it must be suspected in the finding of unknown cause of pneumoperitoneum by complementary examinations. The treatment of choice is splenectomy, because the capsular rupture is the norm in all of them.

Unusual complication of multiple splenic abscesses arising from a feeding jejunostomy tube subsequent to total gastrectomy: A case report and literature review

Splenic abscess is a rare clinical entity. The present study reports a case of a patient that suffered from splenic abscess secondary to septicemia resulting from Klebsiella pneumoniae infection following the removal of the feeding jejunostomy tube that was utilized subsequent to the patient undergoing total gastrectomy as part of the treatment regimen for gastric adenocarcinoma. The early clinical presentation was nonspecific and multiple splenic abscesses were subsequently identified. To reduce the risks of an additional surgical procedure in this particular patient, laparoscopic assisted splenotomy and catheter drainage were performed. Due to the severe complications that occurred in the present patient, no adjuvant chemotherapy was administered. Therefore, the unusual complication of splenic abscess subsequent to total gastrectomy should be noted, and the routine feeding jejunostomy tube placement at the time of total gastrectomy should be discussed and re-assessed.

Splenic infarction - A rare cause of acute abdominal pain following gastric surgery: A case series

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Splenic hilar dissection which is a part of D2 lymphadenectomy has a remarkable role in the curative surgical treatment of gastric cancer.

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Splenic infarction occurs secondary to any injury to splenic vascular structures and has numerous etiologies.

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There has been reported no article about splenic infarction following gastric surgery. Incidence of this complication is still unknown.

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New generation technologies have a major role in surgical area. Particularly, dissection of most regions during surgical resection is performed using vessel sealer device, which is popular in the current surgical era.

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Postoperative acute abdominal pain radiating to left shoulder following gastric surgery should be considered as a sign of possible splenic complication.

Introduction

The dissection of splenic hilar lymph nodes in gastric cancer surgery is indispensable for treating gastric cancers located in the proximal third of the stomach. Splenic vascular injury is a matter of debate resulting on time or delayed splenectomy. We aimed to share our experience and plausible mechanisms causing this complication in two case reports.

Case presentations

Two male patients with gastric cancer were diagnosed with acute splenic infarction following gastric surgery in the early postoperative period. Both underwent emergent exploratory laparotomy. Splenectomy was performed due to splenic infarction.

Discussion

Because we observed this rare complication in recent patients whose surgery was performed using vessel-sealing device for splenic hilar dissection, we suggested that extensive mobilization of the surrounding tissues of splenic vascular structures hilum using the vessel sealer could be the reason.

Conclusion

In case of acute abdominal pain radiating to left shoulder, splenic complications should be taken into consideration in gastric cancer patients performed radical gastrectomy. Meticulous dissection of splenic hilar lymph nodes should be carried out to avoid any splenic vascular injury.

Splenic abscess: Plasmodium vivax with secondary Escherichia coli infection

Splenic abscess is a rare clinical entity as described in literature. The incidence is in the range of 0.14–0.7% and it has a high mortality rate. Hence, it is important to know its clinical presentation and complications, so that it can be treated early. We report a 40-year-old diabetic man who presented with fever with chills and rigor for the last 9 days and heaviness in the left hypochondrium for the last 6 days. He was initially diagnosed as having splenomegaly due to Plasmodium vivax ( P. vivax), but was later found to have a splenic abscess due to Escherichia coli ( E. coli). This was successfully managed by catheter drainage (CD) and antibiotic treatment.

Aseptic splenic abscess as precursory extraintestinal manifestation of inflammatory bowel disease

Splenic abscesses are most often secondary to aerobic bacterial infections due to Streptococcus, Staphylococcus, and Enterococcus species of organisms. Sterile splenic abscesses rarely occur and diagnosis and treatment of those are challenging. We report a case of a previously healthy young female presenting with aseptic splenic abscesses as the initial manifestation of Crohn's disease along with a review of the literature on aseptic splenic abscess as an extraintestinal manifestation of Crohn's disease.

A rare case of splenic abscess with septic peritonitis in a German shepherd dog

BACKGROUND

Splenic abscess is a rare disease with only few reports in small-animal practice as well as in human medicine. It has been mostly reported in immunocompromised patients or following penetrating foreign bodies. This report aims to add to the current veterinary literature on recommended diagnostic tools for splenic abscess, as well as to provide follow-up findings after successful surgical treatment.

CASE PRESENTATION

An 8-year-old male German shepherd dog was admitted to the clinic for evaluation of fever, anorexia, and lethargy for the previous 3 days. During the physical examination, a mass was palpated in the left cranioventral abdomen. Diagnostic imaging including radiography and ultrasonography revealed the presence of a large mass in the spleen and signs of peritonitis. Laboratory tests reflected highly septic pyogranulomatous inflammation and, together with imaging findings, raised a high suspicion of splenic abscess and septic peritonitis. Therapy included complete splenectomy and placement of peritoneal drainage. Bacteriological examination revealed severe infection with Staphylococcus epidermidis and S. pseudintermedius. Histopathological evaluation of the mass confirmed the diagnosis of splenic abscess.

CONCLUSION

Early diagnosis of splenic abscess in small animals requires a high level of suspicion based on clinical and ultrasonographic findings. Immediate surgical intervention is preferable and confirms the diagnosis. Total splenectomy remains the most effective therapy. Although there are many predisposing factors for splenic abscess, the true etiology remains obscure.

Pneumoperitoneum as a result of a ruptured splenic abscess

We encountered a case of ruptured splenic abscess presenting as peritonitis and pneumoperitoneum. Our patient did not have an underlying neoplasm nor was she immunosuppressed. In our case, splenectomy was the treatment of choice in combination with antibiotics, which proved to be a good outcome for the patient. Work-up for the cause of the abscess was negative, although bacteria predominately found in the oral flora were isolated from the abscess. We strongly encourage that splenic abscess be considered on the differential diagnosis of patients presenting with pneumoperitoneum and peritonitis, although a clinical rarity.

Hypervirulent (hypermucoviscous) Klebsiella pneumoniae: a new and dangerous breed

A new hypervirulent (hypermucoviscous) variant of Klebsiella pneumoniae has emerged. First described in the Asian Pacific Rim, it now increasingly recognized in Western countries. Defining clinical features are the ability to cause serious, life-threatening community-acquired infection in younger healthy hosts, including liver abscess, pneumonia, meningitis and endophthalmitis and the ability to metastatically spread, an unusual feature for enteric Gram-negative bacilli in the non-immunocompromised. Despite infecting a healthier population, significant morbidity and mortality occurs. Although epidemiologic features are still being defined, colonization, particularly intestinal colonization, appears to be a critical step leading to infection. However the route of entry remains unclear. The majority of cases described to date are in Asians, raising the issue of a genetic predisposition vs. geospecific strain acquisition. The traits that enhance its virulence when compared with “classical” K. pneumoniae are the ability to more efficiently acquire iron and perhaps an increase in capsule production, which confers the hypermucoviscous phenotype. An objective diagnostic test suitable for routine use in the clinical microbiology laboratory is needed. If/when these strains become increasingly resistant to antimicrobials, we will be faced with a frightening clinical scenario.

Multiple splenic abscesses in 2 patients with myelodysplastic syndrome

Splenic abscess is a rare clinical condition with a high mortality rate. Multiple splenic abscesses, rather than a solitary abscess, are present in immunocompromised states including hematological malignancies. As symptoms of splenic abscesses, fever and abdominal pain, are non-specific, timely and adequate use of imaging studies is crucial for early diagnosis. We report the cases of 2 patients with myelodysplastic syndrome and multiple splenic abscesses. Notwithstanding the higher mortality rate of patients with multiple splenic abscesses as compared with those with a solitary splenic abscess, we successfully treated the 2 patients by using antibiotic therapy and fine needle aspiration.

Splenic abscess: a single institution study and review of the literature

PURPOSE

The aim of this study was to review our experience with splenic abscesses, with respect to the relevant aspects of splenic abscesses and treatment outcomes.

MATERIALS AND METHODS

We reviewed the cases of 18 patients who had splenic abscesses and who were treated at our hospital from November 1993 to December 2008.

RESULTS

The most common symptom at presentation was abdominal pain in 12 patients (66.7%). The median duration from symptom onset until establishment of a diagnosis was 22 days. Streptococcus viridans was the most common pathogen (27.8%), follow by Klebsiella pneumoniae (22.2%). The mortality rate during the inpatient period and the previous 90 days was 16.6%. Three of four patients with Klebsiella pneumoniae showed a single abscess pocket. Four patients (22.2%) underwent percutaneous drainage, eight (44.5%) received antibiotic treatment only and six (33.3%) underwent splenectomy.

CONCLUSION

There is no gold standard for treating splenic abscesses. Treatment should be customized for each patient.

ACR Appropriateness Criteria on percutaneous catheter drainage of infected fluid collections

Abnormal fluid collections occur throughout the body and represent a wide range of pathologies, including abscesses, pseudocysts, cysts, lymphoceles, seromas, bilomas, hematomas, urinomas, and infected neoplasms. Appropriate management often depends on clinical presentation, location, type of collection, early response to treatment, and the presence of complicating factors such as fistulas, septations, and increased viscosity. Physicians should carefully review clinical and imaging findings and make evidence-based recommendations for the best treatment, which may include antibiotics, needle aspiration, percutaneous drainage, endoscopic drainage, or surgical drainage. This paper addresses percutaneous catheter drainage and alternative treatment options for the management of fluid collections and is the result of evidence-based consensus by the ACR Appropriateness Criteria Expert Panel on Interventional Radiology.

Conservative management of isolated splenic abscess in children

INTRODUCTION

Isolated splenic abscesses (SAs) are rare in children. We report a single-center experience with emphasis on their diagnosis, etiology, treatment, and outcome.

METHODS

This is a retrospective review.

RESULTS

Eighteen children (age, 3-16 years; male-female ratio, 5:1) were managed over a period of 8 years in a tertiary-care institution. Presenting symptoms included fever, abdominal pain, and anorexia. Splenomegaly was present in 12 (67%), leukocytosis in 9 (50%), and thrombocytosis in 12 (67%) patients. Associated diseases were thalassemia (1), tuberculosis (1), and typhoid fever (9). Solitary and multiple SAs were seen in equal numbers. Blood culture grew Salmonella paratyphi A in 1 case. Splenic aspirate culture was positive in 3 (Escherichia coli [1], S paratyphi A [1], Acinetobacter [1]). Widal serology was positive in 9 (50%) patients. Management consisted of intravenous broad-spectrum antibiotic therapy in all patients, together with percutaneous aspiration in 10 (56%) cases where the abscess size was greater than 3 cm. All patients responded, and complete resolution was observed.

CONCLUSION

Isolated SA in children responds favorably to conservative treatment with intravenous broad-spectrum antibiotics and percutaneous drainage without the need for splenectomy.

[A 14-year-old healthy boy with splenic abscess due to Salmonella enterica serovar Senftenberg]

Salmonella enterica serovar Senftenberg may very rarely cause splenic abscess, which can be diagnosed using gallium scintigraphy and drained. A 14-year-old boy admitted for stomachache, diarrhea and fever and diagnosed from his symptoms as having enteritis did not respond when treated with fosfomycin, meropenem, and clindamycin. A low-density splenic area seen in abdominal computed tomography on admission did not show contrast medium enhancement. Gallium scintigraphy on hospital day 10, however, showed abnormal splenic accumulation confirming the splenic abscess diagnosis, after which we punctured and drained the abscessout. S. Senftenberg was isolated from pus aspirated pus from the abscess, after which responded well to ceftriaxone and levofloxacin. Follow-up gallium scintigraphy on hospital day 24 showed that the abnormal splenic accumulation had disappeared, after which he has been followed up with abdominal ultrasonography and blood tests as an outpatient. He has experienced no relapse of splenic abscess.

Tubercular splenic abscess in immunocompetent patients: a rare entity

Splenic abscess is an unusual, potentially life threatening condition associated with septiceamic conditions. Splenic abscess due to tuberculosis is a rare entity, specifically seen in immunocompromised individuals. However splenic tubercular abscess in immunocompetent individuals is rarer. We present two cases of splenic tubercular abscess in immunocompetent persons where a diagnosis of tuberculosis was made after splenectomy. The aim of presenting these cases is to stress the fact that tuberculosis should be considered as a differential diagnosis in all cases of splenic abscesses in areas where tuberculosis is endemic.

Management of splenic abscess: report on 16 cases from a single center

OBJECTIVES

Splenic abscess is an uncommon disease, with a reported incidence of 0.14-0.7% in autoptic series. The best treatment option remains unclear. We report our experience of percutaneous drainage of splenic abscess under ultrasound (US) guidance.

METHODS

From 1979 to 2005, 16 consecutive patients (12 male and four female; mean age 39.9 years, range 16-72 years) were diagnosed with splenic abscess by means of US, and were treated with medical therapy alone or combined with US-guided percutaneous aspiration or catheter drainage.

RESULTS

Ten of 16 patients had bacterial abscesses (including one case of tubercular abscess), two had an amebic abscess, and four had fungal abscesses. Seven of ten patients with bacterial abscesses were successfully treated with fine needle aspiration alone, one patient was successfully treated with fine needle aspiration for one abscess and catheter drainage for another, and one patient, who subsequently required a splenectomy for an abdominal trauma, successfully underwent percutaneous catheter drainage alone. Four patients with fungal lesions were treated with medical therapy alone, and two patients later required a splenectomy. One patient with a bacterial abscess due to endocarditis was treated with medical therapy alone, and his recovery was uneventful.

CONCLUSIONS

US-guided percutaneous aspiration of splenic abscesses is a safe and effective procedure. It can be used as a bridge to surgery in patients who are critically ill or have several comorbidities. Percutaneous aspiration may allow complete non-operative healing of splenic abscesses or temporize patients at risk for surgery.

Splenic foreign body in a cat

An 8-year-old domestic shorthair cat was evaluated for a several day history of anorexia and vomiting. Abdominal distention was noted on physical examination and diagnostics including abdominal radiographs and abdominal ultrasound demonstrated the presence of free fluid in the peritoneal cavity. Septic peritonitis was diagnosed on cytologic evaluation of the peritoneal fluid. The cat was taken to surgery and a foreign body composed of plant material was found embedded within the spleen. A splenectomy was performed and both open and active peritoneal drainages were used to successfully treat this case.