Clinical Manifestations of Khalil I.

Splenic Abscess

Abu-Dallo, MD; Yona Manny, MD; Shmuel Penchas, MD; Zvi Eyal,

Two patients with splenic abscess

were successfully treated. In patient, Streptococcus viridans, possibly arising in a dental abscess, led to inflammatory left upper quadrant signs. An exploratory laparotomy was performed, and the spleen, being found enlarged, was removed. The other patient showed no peritoneal signs. Laparotomy was done for pyrexia of unknown origin, and the removal of a normal-sized spleen was elected on the suspicion of lymphosarcoma. The spleen was abscessed, apparently because of old infarcts. A high index of suspicion is important in diagnosis, and selective angiography, not used in these two patients, is recommended.

one

review of the literature on splenic abscess shows that this entity has always been a diagnostic to the clinician. In the past, most cases were diagnosed at autopsy. In three large series, Reid and Lang1 found an incidence of 0.4% of splenic abscess (67 of 16,524 cases). In only one of these patients had the correct diagnosis been made prior to death. This article deals with two such patients whom we have treated recently. The correct diagnosis in both of them was made during surgery, and the definitive treatment was performed. The preoperative clinical picture was characterized in one by an acute condition of the abdomen and in the other by pyrexia of unknown origin.

A challenge

REPORT OF CASES Case 1.—A 68-year-old man was referred because of recurrent bouts of high fever and chills for two months. He was admitted

for investigation. On admission, the patient appeared to be in good general and nutritional condition. His blood pressure was 130/90 mm Hg; pulse, 88 beats per minute and regular. Results of a physical ex¬ amination were completely normal except for high fever. Results of urinalysis, blood and differential cell count, blood urea nitrogen

Accepted for publication Oct 3, 1974. From the Department of Surgery, Hadassah University Hospital, Jerusalem, Israel. Reprint requests to Department of Surgery, Hadassah University Hospital, Kiryat Hadassah, Jerusalem, Israel (Dr. Abu-Dallo).

MD

(BUN), electrolytes, and liver function tests were all within nor¬ mal limits. Sputum, urine, and blood cultures were repeatedly neg¬ ative. Temperature at admission was 39.5 C (103.1 F). A chest roentgenogram and the results of

a

barium

enema were

normal.

During hospitalization, the patient started to complain of vague abdominal pain, and on the third day signs of peritoneal irritation gradually developed in the left upper quadrant. At laparotomy, about 100 ml of cloudy, greenish, free fluid were found in the Douglas area. The omentum and the splenic flexure of the colon were edematous and adhered to the spleen. The spleen was markedly enlarged and contained a huge perforated abscess. Sple¬ nectomy was performed. Streptococcus viridans was cultured from the abscess cavity. On réévaluation of the patient's general condition, a dental abscess was found that could have been the pri¬ mary focus of infection. The patient was treated with high intra¬ venous doses of crystalline penicillin G and underwent an unevent¬ ful recovery. Pathological examination of the spleen showed mul¬ tiple infarcts, one of them with abscess formation and perforation (Fig 1). Comment.—This

patient underwent

arotomy because of signs of

an

an

explorative lap¬

acute condition of the ab¬

domen following a relatively long period of high fever and chills. No localizing signs could be found on physical exam¬ ination and laboratory data were within normal limits. Only the signs of peritonitis, which developed on the third day of admission, led us to perform an urgent exploratory

laparotomy.

Case 2.—A 44-year-old man was hospitalized because of recur¬ rent attacks of high fever and chills, accompanied by low back pain for three weeks. He had been treated for a urinary tract in¬

fection, although this diagnosis was never confirmed. Past history revealed myocardial infarction two years prior to hospitalization. He had been treated irregularly by orally administered anti¬ coagulants. On admission, the patient was found to be in good general con¬ dition. His blood pressure was 130/70 mm Hg; pulse, 120 beats per minute and regular. There was a mild systolic murmur on the apex. The results of the rest of the physical examination were nor¬ mal.

Urinalysis showed proteinuria (4 + ) The white blood cell count

was

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with

13,000/cu

a

normal sediment. a normal dif-

mm, with

ferential count. An excessive erythrocyte sedimentation rate of 110/130 mm was found. All other laboratory results, including liver function, BUN, electrolytes, and bone marrow, were within normal limits. The electrocardiogram was normal, and repeated blood, urine, and sputum cultures were sterile. A roentgenogram of the chest showed mild left pleural effusion. On fluoroscopy, movement of both diaphragms was free. An intravenous pyelogram showed a stone in the right kidney. Results of a study of the upper part of the gastrointestinal tract and barium enemas were normal. During the first week in the hospital, the patient complained of diffuse abdominal pains not accompanied by nausea, vomiting, or diarrhea. An elective exploratory laparotomy for pyrexia of un¬ known origin was performed on the 12th day after admission. On careful exploration, no pathological findings could be detected, ex¬ cept for mild edema of the lesser omentum. A splenectomy was performed on the assumption that the patient might have had lymphosarcoma. While carrying out this procedure, fluctuation was felt in the posterior aspect of the spleen. During division of the splenorenal ligament, a large abscess cavity in the spleen was entered. It should be noted that the pus found was sterile. The histologi¬ cal examination revealed severe pathological changes of the spleen, fresh infarcts with pus in their centers, and an old abscess with pyogenic and fibrotic capsules (Fig 2). The postoperative course was uneventful.

Comment.—This

patient underwent

an

exploratory lap¬

arotomy because of abdominal pain and pyrexia of

un¬

known

origin. Left pleural effusion was the only possible localizing sign preoperatively. There was nothing in the appearance of the anterior aspect of the spleen to suggest a splenic abscess. Only the very rare possibility of lympho¬ sarcoma of the spleen led us to remove it. COMMENT

The

entity of splenic abscess has been dealt with for Hippocrates was the first to describe this dis¬ ease. According to Wolfson,2 classification of splenic ab¬ scess is based on three different etiologic factors: (1) trau¬ matic, (15%); (2) pathologic processes, such as neoplasm of many years.

the colon or stomach (10%); and (3) metastastic infection via the blood from a distant focus (75%). Our two patients probably belong to the third group. In the first patient, the dental abscess may be considered as having been the source of recurrent transient bacteremia with septic métastases. The histological findings of mul¬ tiple splenic infarctions in both patients is likely the out¬ come of embolie phenomena. In the second patient, the right nephrolithiasis could have been the source of concealed infection complicated by transient bacteremia. According to Friedberg, bacterial endocarditis is the main reason for splenic infarcts leading to splenic ab¬ scess.3 Bacteremia, per se, is not enough to cause a splenic abscess. Splenic infarcts are the predisposing factors. The clinical picture of this disease is complicated be¬ cause the vast majority of patients receive antibiotic ther¬ apy prior to admission. This adds much to the delay in diagnosis characterizing many of the published case re¬

ports.4 Davidson et al5

reported a case in which the disease was

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manifested as a left subphrenic abscess. Among the three patients described by Pickleman et al,6 two were operated on with the signs of diffuse generalized peritonitis. In the first patient, the correct preoperative diagnosis was made by puncturing the left subphrenic space. In the second, the diagnosis was not made intraoperatively in a child who underwent an appendectomy. Postoperatively, his clinical condition markedly deteriorated, a left pleural effusion of pussy material necessitated continuous intercostal drain¬ age, and only later was the diseased spleen removed. In their third patient, the condition also was not diagnosed

during exploratory laparotomy. Only postoperatively did a scan of the spleen by technetium Tc 99m reveal a large filling defect. In our second patient, the diagnosis could be easily missed during explorations. A high index of suspicion is mandatory for leading to further investigation. Selective angiography is recommended as a useful method for early diagnosis and treatment. Before the antibiotic era, splenotomy and drainage of

50 Years in the Archives of

abscess were used in some cases.7 Today, the treatment of choice for splenic abscess, is of course, splenectomy. an

Nonproprietary Name Technetium Tc 99m-iVeimoiec,

and Trademarks of

Pertgen-99m, Renotec,

References 1. Reid

916, 1954.

SE, Lang SY: Abscess of the spleen.

Analysis of Forty-Two Cases "1. Abdominal viscera are insensitive to pain so far as the cutting, crushing, or cauterizing of an operation is an inadequate stimulus for the production of such pain. The breaking of conductivity in the splanchnic nerves for the relief of visceral pain in abdominal operations is, therefore, not in accordance with sound principles of anatomy and physiology. 2. The pain experienced by the patient in an abdominal operation under local anesthesia is caused by the stimulation of spinal and not sympathetic nerve filaments, since it arises as the result of either traction on mesenteries or direct irritation of parietal peritoneum. Paravertebral block of the fifth dorsal to third lumbar nerves for intra-abdominal anesthesia is anatomically and physiologically correct, but entirely impractical. 3. Clinical experience with splanchnic anesthesia proves it to be inefficient, since, by its use, a complete surgical anesthesia of the abdominal cavity is not produced. It is the least important of all the factors concerned in the success of an abdominal operation under local anesthesia. 4. Besides the production of an inadequate intra-abdominal anesthesia, splanchnic nerve block is not free from danger, a fact acknowledged by most users of the method. Four deaths in a collected series of 1,375 operations is a higher mortality than that recorded for spinal anesthesia." Surg 10:699-719,

Am J Surg 88:912\x=req-\

2. Wolfson IN: Abscess of spleen. N Engl J Med 230:135-137, 1944. 3. Friedberg CK: Diseases of the Heart, ed 3. Philadelphia, WB Saunders Co, 1966, p 1385. 4. Chaffee JS, Lasher RL, Tredway JB: Splenic abscess. Ann Surg 148:979-984, 1958. 5. Davidson SG, Daig YA, Everard GJH: Acute splenic abscess. J R Coll Surg Edinb 6:44-50, 1960. 6. Pickleman JR, Paloyan E, Block GE: The surgical significance of splenic abscess. Surgery 68:287-293, 1970. 7. Walker IJ: Abscess of spleen. N Engl J Med 203:1025-1028, 1930.

Ago

Meeker WR: Arch

Technekow

generator, Technetope, Ultra-technekow-generator.

Surgery

Splanchnic Anesthesia:

Drug

An

1925.

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Clinical manifestations of splenic abscess.

Two patients with splenic abscess were successfully treated. In one patient, Streptococcus viridans, possibly arising in a dental abscess, led to infl...
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