Clinical and Roentgenographic in Splenic Abscess Franklin J.
Miller, Jr, MD; Franklin J. Rothermel, MD; Martin J. O'Neil, MD; Stephen
\s=b\A splenic abscess developed in a 16-year-old boy following supposed viral illness and left lower thoracic trauma. Preoperative diagnosis was at first obscured, but a spleen scan suggested fractured spleen and a splenic arteriogram showed a "subcapsular hematoma" and an aneurysm of the left hepatic artery. A 1,800-gm spleen containing one large abscess and one small one was removed. Splenic abscess is rare and, before modern methods of spleen scan and arteriography, rarely diaga
nosed.
(Arch Surg 111:1156-1159, 1976) an uncommon entity that, if unrecog¬ results in the death of the patient.1 nized, usually Interest in the diagnosis of splenic abscess has increased, as noted by the number of reports in the literature since 1970.'" Reid and Lang7 reported 67 cases in 16,574 autopsies in 1954, while Gelfand^ described the largest clinical series in 1947 with 40 patients in Rhodesia, most of whom had SS, SC, or SA hemoglobinopathies. Cockshott and Weaver" believe that splenic infarction in patients with a hemoglobinopathy is the underlying cause, and do not believe in the entity of idiopathic primary tropical splenic abscess. The cause of splenic abscess usually can be attributed to one of the five following categories outlined by Zatzkin et al1": (1) splenic infarction, (2) trauma, (3) mycotic emboli, (4) local extension of infection, and (5) idiopathic. The current report describes a young patient with splenic abscess with
Splenic
Accepted
abscess is
for publication June 9, 1976. From the departments of radiology (Drs Miller and Rothermel) and surgery (Dr O'Neil) and the Division of Pediatric Surgery (Dr Shochat), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey. Reprint requests to University of Utah Medical Center, Salt Lake City, UT 84112 (Dr Miller).
J.
Findings
Shochat, MD
mycotic aneurysm and reviews the previous¬ ly reported major series. an
associated
REPORT OF A CASE This 16-year-old boy was first seen for rheumatic heart disease with mitral insufficiency at age 10. Monthly penicillin G benzathine suspension was begun at that time and he remained physically active without significant sequelae. In November 1974, malaise, fever, and headaches developed. He was initially thought to have a viral illness but was empirically begun on a regimen of ampicillin sodium. During this time he slipped and fell in a bathtub, injuring his left lower rib cage. Five days later he was hospitalized by his family physician because of persistent fever, lower abdominal pain, and dysuria. Physical examination at this time was normal except for a grade 2/6 systolic murmur at the cardiac apex, which had not changed in character. A blood culture obtained shortly after admission grew Staphylococcus aureus, and urine cultures also showed a scanty growth (less than 100,000 colonies per milliliter) of S aureus. Intravenous methicillin sodium therapy was then begun and a presumptive diagnosis of subacute bacterial endocarditis was made. The initial electrocardiogram revealed mild left ventricular hypertrophy, the chest roentgenogram was normal, and an intra¬ venous urogram performed because of microscopic hematuria was also normal. Despite intravenously administered methicillin, the patient's course continued to be septic, with daily temperature spikes to 40 C. Ten days following admission, therapy with intravenously administered nafcillin sodium was started, and over the next four days his temperature returned to normal. He remained afebrile while receiving nafcillin, but on the 29th hospital day, a left upper quadrant mass was felt. A second chest roentgenogram revealed elevation of the left hemidiaphragm with a small pleural effusion. An upper gastrointestinal x-ray series showed anterior and medial displacement of the stomach (Fig 1). A second intravenous urogram revealed downward displacement of the left kidney. The patient was then transferred to our hospital for further evaluation. Physical examination revealed a grade 2/6 systolic murmur at the left cardiac apex. There was a large left upper
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/14/2015
Fig 1.—Gastrointestinal x-ray displacing stomach medially.
film demonstrates
splenomegaly
Fig 3.—Selective splenic arteriogram demonstrates gross displacement of capsular vessels and minimal irregularity of vessels along inferior border of spleen (arrow).
Fig 2.—Abdominal aortogram left hepatic artery (arrow).
demonstrates
mycotic
aneurysm of
mass extending 5 cm below the left costal margin. The remainder of the examination was unremarkable. A spleen scan was interpreted as showing a fractured spleen with subcapsular hematoma. A splenic arteriogram (Fig 2 and 3) suggested a large subcapsular hematoma but also revealed a false aneurysm of the left hepatic artery. The preoperative diagnosis was an infected subcapsular hematoma. On Jan 8, 1975, at laparotomy, the spleen was enormous, occupying the entire left upper quadrant. There were multiple adhesions to the left lobe of the liver and diaphragm. The spleen was removed intact and a sump drain was placed in the left upper quadrant. There was no evidence of the subcapsular hematoma suspected preoperatively. Deep within the left lobe of the liver a 3-cm pulsatile mass was felt. No further surgery was performed. The patient is doing well and has no symptoms on follow-up. Pathologic examination of the spleen revealed a large splenic 21 14 abscess (Fig 4) weighing 1,880 gm and measuring 10.5 cm. Near the hilum of the spleen a second abscess measuring 3.5 cm was seen. Anaerobic and aerobic cultures were negative; however, clumps of Gram-positive cocci were seen within the necrotic debris of the abscess cavity.
quadrant abdominal
The
patient's preoperative course was unremarkable and he was
discharged on the tenth postoperative day. Oral cloxacillin sodium
monohydrate therapy was continued for an additional six weeks. He is presently asymptomatic and has no physical restrictions. A follow-up liver scan three months postoperatively was normal.
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Fig 4.—Surgical specimen demonstrating gross enlargement
Findings No. of Patients
Source, yr Present case, 1976 Abu-Dallo et al,7 1975 Coopersmith et al,'7 1975 Jacobs et al,' 1974 Lepage et al/ 1972 Baitaxe et al,'1 1972 Pickleman et al.1 1970 Frankel," 1966 Zatzkin et al," 1964 McSherry and Dineen,'6 1962 Cockshott and Weaver,' 1961 Chaffee et al,'7 1958 Whelan,'» 1957 Gelfand," 1947 Billings,"' 1928
in
Previously Reported
Age Range,
Angiograms
Mycotic Aneurysms
1/1
1/1
16 44-68 20-55 61
2/4
NAt NA 24-57 12
40 55
near
hilum
(arrow).
Cases and Current Case
Abnormal yr
1/1
46 3-83 2-50 19-64 22
Abnormal Technetium Tc 99m Scans
Deaths
1/1 1/1
0/1s 3/3 1/1 NA NA
12/3Í NA 1/4 NA 10
NA
NA
"Abnormal gallium citrate Ga 67 scan, false-negative technetium fNot available. "{Three patients under age 10 died but associated diseases were
Tc 99m cause
COMMENT
the
spleen. Smaller second abscess is
of
diagnosis of splenic abscess Although historically was rarely made prior to autopsy,7 with increased clinical awareness and the use of arteriography a preoperative diagnosis can be made in the appropriate clinical setting.1 Cases previously reported are summarized in the Table. Patients usually have fever, leukocytosis, and left upper quadrant pain. Predisposing factors, such as recent abdom¬ inal trauma or a recent infection, should be sought in the history. On physical examination a friction rub, although rare, may be audible. Chest and abdominal roentgeno¬ grams may reveal a left-sided pleural effusion, elevation of the left hemidiaphragm, and sometimes splenomegaly. If a
scan.
of death in two of the three.
fluid level can be seen within the spleen, one can be confident of the presence of a splenic abscess." Spleen scanning with technetium Tc 99m sulfur colloid shows either single or multiple defects.'71 Gallium citrate Ga 67 scanning at 24 and 48 hours may be helpful, and indeed was abnormal when a colloid scan was normal in a patient described by Coopersmith et al.'7 Ultrasound has been reported17 as accurate in five patients with splenomegaly from trauma, and should be of value in the detection of abscess also. Computerized tomog¬ raphy has not been evaluated but should also be veryhelpful in detecting abscess formation. Two different angiographie patterns have been
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/14/2015
described in the literature. The first type, as described by Reuter and Redman," mimics subcapsular hematoma, and is characterized by (1) tortuous arteries on the periphery of a vascular mass, and (2) collateral veins, if the splenic vein is narrowed or obstructed. The second type is described by Jacobs et al,1 and involves splenomegaly with irregular mass. It is characterized by (1) ill-defined margins to the mass; (2) no vascular rim (seen frequently in echinococcal cysts); (3) stretched vessels but no arterial encasement; and (4) normal veins. In our patient, as well as in two patients reported on by Jacobs et al,' mycotic aneurysms were seen. These aneu¬ rysms were found in the splenic, hepatic, or superior mesenterie arteries. In the presence of abnormal angio-
graphie findings in the spleen with an aneurysm of a visceral vessel, one can be confident of a diagnosis of splenic abscess. Although the natural history of mycotic aneurysms of the abdominal vessels is not available in any large series to our knowledge, in a patient recently described at a clinicopathologic conference, symptoms did develop ten years later and he required resection of a mycotic aneurysm." Nonproprietary
Names and Trademarks of
Drugs
Ampicillin sodium— Polycillin-N, Penbritin-S, Amcill-S, OmnipenN, Principen/N, Alpen-N. Cloxacillin sodium monohydrate- Tegapen.
References 1. Pickleman JR, Palyoan E, Block GE: The surgical significance of splenic abscess. Surgery 68:287-293, 1970. 2. Abu-Dallo KI, Manny Y, Penchas S, et al: Clinical manifestations of splenic abscess. Arch Surg 110:281-283, 1975. 3. Jacobs RP, Shanser JD, Lawson DL, et al: Angiography of splenic abscesses. Am J Roentgenol Radium Ther Nucl Med 122:419-424, 1974. 4. Lepage JR, Pratt AD Jr, Miale A, et al: Diagnosis of splenic abscess by radionuclide scanning and selective arteriography. J Nucl Med 13:331-332,
1972.
5. Baltaxe
HA, Watson RC, Levin DC: Angiographic appearance of Angiology 23:316-328, 1972. 6. Reuter SR, Redman HC: Gastrointestinal Angiography. Philadelphia, WB Saunders Co, 1972, pp 202-209. 7. Reid SE, Lang SJ: Abscess of the spleen. Am J Surg 88:912-917,
splenic
masses.
1954. 8. Gelfand M: Primary splenic abscess. Lancet 253:904-905, 1947. 9. Cockshott WP, Weaver EJM: Primary tropical splenic abscess: A misnomer. Br J Surg 49:665-669, 1961. 10. Zatzkin HR, Drazan AD, Irwin GA: Roentgenographic diagnosis of
splenic
abscess. Am J Roentgenol Radium Ther Nucl Med 91:896-899, 1964. 11. Davidson SG, Doig JA, Everard GJH: Acute splenic abscess. J Coll Surg 6:44-50, 1960. 12. Coopersmith A, Ritchey AK, Zinkham WH: Fever of unknown origin and the value of gallium-67 and technetium-99M for defining abnormality of the spleen: A case report. John Hopkins Med J 137:51-54, 1975. 13. Richardson R, Norton LW, Eule J, et al: Accuracy of ultrasound in diagnosing abdominal masses. Arch Surg 110:933-939, 1975. 14. Case Records of the Massachusetts General Hospital, Case 19-1975. N Engl J Med 292:1068-1073, 1975. 15. Frankel A: Splenic abscess. J Mt Sinai Hosp 33:404, 1966. 16. McSherry CK, Dineen P: The significance of splenic abscess. Am J Surg 103:618-623, 1962. 17. Chaffee JS, Lasher RL, Tredway JB: Splenic abscess: Report of four cases. Ann Surg 148:979-984, 1958. 18. Whelan TJ: Abscess of the spleen. Am J Surg 94:945-950, 1957. 19. Billings AE: Abscess of the spleen. Ann Surg 88:416-428, 1928.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/14/2015
Miller, Jr, MD; Franklin J. Rothermel, MD; Martin J. O'Neil, MD; Stephen
\s=b\A splenic abscess developed in a 16-year-old boy following supposed viral illness and left lower thoracic trauma. Preoperative diagnosis was at first obscured, but a spleen scan suggested fractured spleen and a splenic arteriogram showed a "subcapsular hematoma" and an aneurysm of the left hepatic artery. A 1,800-gm spleen containing one large abscess and one small one was removed. Splenic abscess is rare and, before modern methods of spleen scan and arteriography, rarely diaga
nosed.
(Arch Surg 111:1156-1159, 1976) an uncommon entity that, if unrecog¬ results in the death of the patient.1 nized, usually Interest in the diagnosis of splenic abscess has increased, as noted by the number of reports in the literature since 1970.'" Reid and Lang7 reported 67 cases in 16,574 autopsies in 1954, while Gelfand^ described the largest clinical series in 1947 with 40 patients in Rhodesia, most of whom had SS, SC, or SA hemoglobinopathies. Cockshott and Weaver" believe that splenic infarction in patients with a hemoglobinopathy is the underlying cause, and do not believe in the entity of idiopathic primary tropical splenic abscess. The cause of splenic abscess usually can be attributed to one of the five following categories outlined by Zatzkin et al1": (1) splenic infarction, (2) trauma, (3) mycotic emboli, (4) local extension of infection, and (5) idiopathic. The current report describes a young patient with splenic abscess with
Splenic
Accepted
abscess is
for publication June 9, 1976. From the departments of radiology (Drs Miller and Rothermel) and surgery (Dr O'Neil) and the Division of Pediatric Surgery (Dr Shochat), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey. Reprint requests to University of Utah Medical Center, Salt Lake City, UT 84112 (Dr Miller).
J.
Findings
Shochat, MD
mycotic aneurysm and reviews the previous¬ ly reported major series. an
associated
REPORT OF A CASE This 16-year-old boy was first seen for rheumatic heart disease with mitral insufficiency at age 10. Monthly penicillin G benzathine suspension was begun at that time and he remained physically active without significant sequelae. In November 1974, malaise, fever, and headaches developed. He was initially thought to have a viral illness but was empirically begun on a regimen of ampicillin sodium. During this time he slipped and fell in a bathtub, injuring his left lower rib cage. Five days later he was hospitalized by his family physician because of persistent fever, lower abdominal pain, and dysuria. Physical examination at this time was normal except for a grade 2/6 systolic murmur at the cardiac apex, which had not changed in character. A blood culture obtained shortly after admission grew Staphylococcus aureus, and urine cultures also showed a scanty growth (less than 100,000 colonies per milliliter) of S aureus. Intravenous methicillin sodium therapy was then begun and a presumptive diagnosis of subacute bacterial endocarditis was made. The initial electrocardiogram revealed mild left ventricular hypertrophy, the chest roentgenogram was normal, and an intra¬ venous urogram performed because of microscopic hematuria was also normal. Despite intravenously administered methicillin, the patient's course continued to be septic, with daily temperature spikes to 40 C. Ten days following admission, therapy with intravenously administered nafcillin sodium was started, and over the next four days his temperature returned to normal. He remained afebrile while receiving nafcillin, but on the 29th hospital day, a left upper quadrant mass was felt. A second chest roentgenogram revealed elevation of the left hemidiaphragm with a small pleural effusion. An upper gastrointestinal x-ray series showed anterior and medial displacement of the stomach (Fig 1). A second intravenous urogram revealed downward displacement of the left kidney. The patient was then transferred to our hospital for further evaluation. Physical examination revealed a grade 2/6 systolic murmur at the left cardiac apex. There was a large left upper
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/14/2015
Fig 1.—Gastrointestinal x-ray displacing stomach medially.
film demonstrates
splenomegaly
Fig 3.—Selective splenic arteriogram demonstrates gross displacement of capsular vessels and minimal irregularity of vessels along inferior border of spleen (arrow).
Fig 2.—Abdominal aortogram left hepatic artery (arrow).
demonstrates
mycotic
aneurysm of
mass extending 5 cm below the left costal margin. The remainder of the examination was unremarkable. A spleen scan was interpreted as showing a fractured spleen with subcapsular hematoma. A splenic arteriogram (Fig 2 and 3) suggested a large subcapsular hematoma but also revealed a false aneurysm of the left hepatic artery. The preoperative diagnosis was an infected subcapsular hematoma. On Jan 8, 1975, at laparotomy, the spleen was enormous, occupying the entire left upper quadrant. There were multiple adhesions to the left lobe of the liver and diaphragm. The spleen was removed intact and a sump drain was placed in the left upper quadrant. There was no evidence of the subcapsular hematoma suspected preoperatively. Deep within the left lobe of the liver a 3-cm pulsatile mass was felt. No further surgery was performed. The patient is doing well and has no symptoms on follow-up. Pathologic examination of the spleen revealed a large splenic 21 14 abscess (Fig 4) weighing 1,880 gm and measuring 10.5 cm. Near the hilum of the spleen a second abscess measuring 3.5 cm was seen. Anaerobic and aerobic cultures were negative; however, clumps of Gram-positive cocci were seen within the necrotic debris of the abscess cavity.
quadrant abdominal
The
patient's preoperative course was unremarkable and he was
discharged on the tenth postoperative day. Oral cloxacillin sodium
monohydrate therapy was continued for an additional six weeks. He is presently asymptomatic and has no physical restrictions. A follow-up liver scan three months postoperatively was normal.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/14/2015
Fig 4.—Surgical specimen demonstrating gross enlargement
Findings No. of Patients
Source, yr Present case, 1976 Abu-Dallo et al,7 1975 Coopersmith et al,'7 1975 Jacobs et al,' 1974 Lepage et al/ 1972 Baitaxe et al,'1 1972 Pickleman et al.1 1970 Frankel," 1966 Zatzkin et al," 1964 McSherry and Dineen,'6 1962 Cockshott and Weaver,' 1961 Chaffee et al,'7 1958 Whelan,'» 1957 Gelfand," 1947 Billings,"' 1928
in
Previously Reported
Age Range,
Angiograms
Mycotic Aneurysms
1/1
1/1
16 44-68 20-55 61
2/4
NAt NA 24-57 12
40 55
near
hilum
(arrow).
Cases and Current Case
Abnormal yr
1/1
46 3-83 2-50 19-64 22
Abnormal Technetium Tc 99m Scans
Deaths
1/1 1/1
0/1s 3/3 1/1 NA NA
12/3Í NA 1/4 NA 10
NA
NA
"Abnormal gallium citrate Ga 67 scan, false-negative technetium fNot available. "{Three patients under age 10 died but associated diseases were
Tc 99m cause
COMMENT
the
spleen. Smaller second abscess is
of
diagnosis of splenic abscess Although historically was rarely made prior to autopsy,7 with increased clinical awareness and the use of arteriography a preoperative diagnosis can be made in the appropriate clinical setting.1 Cases previously reported are summarized in the Table. Patients usually have fever, leukocytosis, and left upper quadrant pain. Predisposing factors, such as recent abdom¬ inal trauma or a recent infection, should be sought in the history. On physical examination a friction rub, although rare, may be audible. Chest and abdominal roentgeno¬ grams may reveal a left-sided pleural effusion, elevation of the left hemidiaphragm, and sometimes splenomegaly. If a
scan.
of death in two of the three.
fluid level can be seen within the spleen, one can be confident of the presence of a splenic abscess." Spleen scanning with technetium Tc 99m sulfur colloid shows either single or multiple defects.'71 Gallium citrate Ga 67 scanning at 24 and 48 hours may be helpful, and indeed was abnormal when a colloid scan was normal in a patient described by Coopersmith et al.'7 Ultrasound has been reported17 as accurate in five patients with splenomegaly from trauma, and should be of value in the detection of abscess also. Computerized tomog¬ raphy has not been evaluated but should also be veryhelpful in detecting abscess formation. Two different angiographie patterns have been
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/14/2015
described in the literature. The first type, as described by Reuter and Redman," mimics subcapsular hematoma, and is characterized by (1) tortuous arteries on the periphery of a vascular mass, and (2) collateral veins, if the splenic vein is narrowed or obstructed. The second type is described by Jacobs et al,1 and involves splenomegaly with irregular mass. It is characterized by (1) ill-defined margins to the mass; (2) no vascular rim (seen frequently in echinococcal cysts); (3) stretched vessels but no arterial encasement; and (4) normal veins. In our patient, as well as in two patients reported on by Jacobs et al,' mycotic aneurysms were seen. These aneu¬ rysms were found in the splenic, hepatic, or superior mesenterie arteries. In the presence of abnormal angio-
graphie findings in the spleen with an aneurysm of a visceral vessel, one can be confident of a diagnosis of splenic abscess. Although the natural history of mycotic aneurysms of the abdominal vessels is not available in any large series to our knowledge, in a patient recently described at a clinicopathologic conference, symptoms did develop ten years later and he required resection of a mycotic aneurysm." Nonproprietary
Names and Trademarks of
Drugs
Ampicillin sodium— Polycillin-N, Penbritin-S, Amcill-S, OmnipenN, Principen/N, Alpen-N. Cloxacillin sodium monohydrate- Tegapen.
References 1. Pickleman JR, Palyoan E, Block GE: The surgical significance of splenic abscess. Surgery 68:287-293, 1970. 2. Abu-Dallo KI, Manny Y, Penchas S, et al: Clinical manifestations of splenic abscess. Arch Surg 110:281-283, 1975. 3. Jacobs RP, Shanser JD, Lawson DL, et al: Angiography of splenic abscesses. Am J Roentgenol Radium Ther Nucl Med 122:419-424, 1974. 4. Lepage JR, Pratt AD Jr, Miale A, et al: Diagnosis of splenic abscess by radionuclide scanning and selective arteriography. J Nucl Med 13:331-332,
1972.
5. Baltaxe
HA, Watson RC, Levin DC: Angiographic appearance of Angiology 23:316-328, 1972. 6. Reuter SR, Redman HC: Gastrointestinal Angiography. Philadelphia, WB Saunders Co, 1972, pp 202-209. 7. Reid SE, Lang SJ: Abscess of the spleen. Am J Surg 88:912-917,
splenic
masses.
1954. 8. Gelfand M: Primary splenic abscess. Lancet 253:904-905, 1947. 9. Cockshott WP, Weaver EJM: Primary tropical splenic abscess: A misnomer. Br J Surg 49:665-669, 1961. 10. Zatzkin HR, Drazan AD, Irwin GA: Roentgenographic diagnosis of
splenic
abscess. Am J Roentgenol Radium Ther Nucl Med 91:896-899, 1964. 11. Davidson SG, Doig JA, Everard GJH: Acute splenic abscess. J Coll Surg 6:44-50, 1960. 12. Coopersmith A, Ritchey AK, Zinkham WH: Fever of unknown origin and the value of gallium-67 and technetium-99M for defining abnormality of the spleen: A case report. John Hopkins Med J 137:51-54, 1975. 13. Richardson R, Norton LW, Eule J, et al: Accuracy of ultrasound in diagnosing abdominal masses. Arch Surg 110:933-939, 1975. 14. Case Records of the Massachusetts General Hospital, Case 19-1975. N Engl J Med 292:1068-1073, 1975. 15. Frankel A: Splenic abscess. J Mt Sinai Hosp 33:404, 1966. 16. McSherry CK, Dineen P: The significance of splenic abscess. Am J Surg 103:618-623, 1962. 17. Chaffee JS, Lasher RL, Tredway JB: Splenic abscess: Report of four cases. Ann Surg 148:979-984, 1958. 18. Whelan TJ: Abscess of the spleen. Am J Surg 94:945-950, 1957. 19. Billings AE: Abscess of the spleen. Ann Surg 88:416-428, 1928.
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