Aust. N . Z . J . Surg. 1992,62,780-784
SPLENIC ABSCESS LONDONLUCIENP. J . OOI,*RAJ NAMBIAR,*ABURAUFF,~ PETER0. P. MACK” AND TE Lu YAP* *Department of Surgery, Singapore General Hospital and ‘Department of Surgery, National University Hospital, Singapore Isolated splenic abscess is an uncommon condition. Seven cases seen between 1980 and 1990 are reviewed. The clinical presentation is non-specific and diagnosis is usually delayed. Computerized tomography allowed for accurate diagnosis in all cases. Pseudomonas species as a causative organism is reported to be rare, but were present in three of the present cases. Antibiotic therapy alone is insufficient and splenectomy remains the treatment of choice. Key words: computerized tomography, Pseudornonas, spleen, splenectomy.
Introduction Isolated splenic abscess is a rare entity first described by Hippocrates.’ In the early reviews, splenic abscesses were due mainly to typhoid fever, malaria, dysentery and dengue Splenic abscesses secondary to appendicular abscess, salpingitis, puerperal fever, carbuncle and wounds of the skin were also described.’ In more recent times, with better control of typhoid fever. malaria and dysentery, and the introduction of antibiotics in the 1930s, a changing trend has been observed in the causative factors. Trauma, especially with the increasing popularity of splenic conservation surgery has assumed a new import a n ~ e . ~ -Immunodeficiency ’ states due to disease or during immunosuppression, blood disorders, and heroin addiction with bacterial endocarditis are being increasingly reported as predisposing causes of splenic abscesses.538-’ The aim of this paper is to highlight the nonspecific clinical presentations, the changing trends in both diagnostic and therapeutic modalities, and the presence of an unusually higher frequency of Pseudomonas species in the present series.
’
Clinical material During a 10 year period, between 1980 and 1990, a total of seven patients with isolated splenic abscesses were seen at the Departments of Surgery at the National University Hospital and Singapore General Hospital (Table 1). Correspondence: Dr Lucien Ooi, Department of Surgery, Singapore General Hospital, Outram Road, Singapore 0316. Accepted for publication 5 March 1992
There were five males and two females, with ages ranging from 20 to 62 years (mean age of 45 years). The slight male predominance and age range between 6 months and 83 years is observed in most series including the present 0ne.5~6,8-10,12313 Four were Chinese, two were Malays and one was Indian. Racial distinction has never been reported, and there was no predominance in a particular race that differed from demographic proportions. Symptoms are usually non-specific. Fever was observed in all patients. Left upper quadrant pain was observed in five of seven, with only three having left hypochondria1 tenderness as well. This is consistent with previously quoted figures of 37.6 to 39.2% for pain, and 38.2 to 42.1% for Splenomegaly was found in only four patients, and this made the clinical diagnosis of a splenic abscess difficult in most of the cases. The pre-operative diagnosis of splenic abscess in all the patients was accomplished by positive computerized tomographic (CT) scan findings of generally hypodense, usually multiple and often confluent lesions in the spleen (Fig. A preliminary ultrasound before CT scan was available in two patients and these both showed splenomegaly with multiple lesions of mixed echogenicity and anechoic features, which is diagnostic of splenic abscess.I6 Some studies have found invariable leucocytosis,6,8,’obut we have found white blood cell counts to be unreliable and not markedly raised in most situations, with values ranging between 9100 to 17 800 cells/mm3. It has been suggested that previous antibiotic therapy can cause this inconsistency, ” but it was not possible to obtain these data from many of the case records.
Left hypochondrial pain and fever
PUO*
CH
MAL
F
M
F
54
53
34
5WCM (1989)
6ABSt (1990)
7HQL 62 (1991)
Left hypochrondrial pain and loss of appetite and weight
Post laparotomy sepsis and left hypochondria1 pain
Splenomegaly
12 850 Not done
Sterile
Abscess Pseudomonas (multiple) pseudomallei
-
Not done
Hepatosplenomegaly
Sterile
Abscess Sterile (multiple)
Abscess
9 100
Abscess (single)
Sterile
Lactohacillus, Swept milleri
Sterile
Tender splenomegaly
Abscess PseudomonuA (multiple)
Not done
17 800
Malignant B cell lymphoma IIB ES
Septicaemia, ARDS
Benign cavernous haemangioma of spleen, diabetes mellitus
Post laparotomy septicaemia
None
Sterile
Tender left hypochondrium
t Patients previously reported by P. 0. P. Mack and R. Nambiar CH: Chinese; MAL: Malay; IND: Indian.
* PUO - Pyrexia of unknown origin.
CH
IND
M
Pseudomonas pseudomallei osteomyelitis
Penetrating trauma with piece of wood in spleen
Associated condition
Pseudomonas pseudomallei
NA
NA
Sterile
Abscess culture
Blood culture
Abscess Sterile (multiple)
Abscess (solitary)
Abscess (solitary)
CT result
Not done
Abwss
Not done
-
13 100
Ultrasound result
Leucocyte count (mm')
-
Fever, splenomegaly
4 SPA (1988)
CH
M
PUO*
20
Fever
Tender left upper quadrant
Signs
~
Osteomyelitis femur with recurrent left hypochondrial pain and fever
3MSH (1988)
MAL
M
52
PUO* 3 weeks after trauma 10left flank
2 MBlt (1987)
CH
Symptoms
M
Age Sex Race
I NTB 40 (1985)
Case no.
~~
Table 1. Clinical findings in patients with splenic abscess Outcome
Splenectomy Died
Splenectomy Died
Splenectomy Well
Splenectomy Well
Splenectomy Well
Splenectomy Well
Splenectomy Well
Treatment
782
001ETAL.
Fig. 1. Computerized tomography scan showing a large splenic abscess (case 2 # WCM).
Management Based on the CT scan evidence of multiple splenic abscesses, two patients were treated with antibiotic therapy alone and there was initial resolution of the disease. The disease flared up within 6 months in both cases (case 2 and 6) and splenectomy was then performed, with one patient (case 6) succumbing to overwhelming Pseudomonas pseudomallei septicaemia and adult respiratory distress syndrome (ARDS). The other recovered uneventfully. The remaining five patients underwent splenectomy under antibiotic cover. Three had multiple abscesses, one of which occurred in a spleen with a benign cavernous haemangioma (case 5). The other two were in solitary abscesses: one with a localized rupture found only at laparotomy after a previous penetrating injury to the left side 3 weeks earlier (case l), and the other in a diseased spleen complicated by lymphoma which had perforated into the stomach (case 7). Both solitary abscesses had localized rupture or perforation that was not detected by CT scan, and only discovered at the time of operation.
Results Pus for culture was obtained from all the spleens at the time of operation. Four cultures were sterile and were from patients who had all received antibiotic therapy before operation. Two of these had sterile blood cultures as well, but the other two had Pseudomonas species cultured from the blood preoperatively. This demonstrated the efficacy of the clearance of organisms by intravenous antibiotic therapy in some patients. Two patients had pre-operative sterile blood cultures, but cultures taken later from the spleen grew Pseudomonas pseudomallei in one (case 2), and Lactobacillus plus Streptococci milleri in the other
(case 7). This highlights the well known concept that intravenous therapy alone does not eradicate disease in an abscess, which always requires drainage. Culture results were unavailable in one case. All splenectomy specimens were subjected to histological examination which confirmed the diagnosis of splenic abscess in all seven cases. There were two cases with a solitary abscess and both had pathology in the spleen: one was secondary to foreign body penetration (case I); the other had lymphoma of the spleen (case 7). The remaining five had multiple abscesses: four in normal spleens and one in a benign splenic cavernous haemangioma. All patients survived splenectomy and five recovered completely without complications. Mean follow-up for these five patients was 4 years with a range between 2 and 7 years. Two patients died. Case 6 relapsed after previous resolution with antibiotic therapy alone. He succumbed to ARDS and fulminant Pseudomonas pseudomallei septicaemia despite antibiotic therapy and splenectomy . Case 7 underwent splenectomy successfully for a malignant B cell lymphoma of the spleen that had perforated into the stomach, resulting in an abscess. While under chemotherapy, she developed pancytopenia and fulminant septicaemia, which was indistinguishable from overwhelming post-splenectomy infection (OPSI).
Discussion Less than 400 cases of isolated splenic abscess have been reported in the world lite ra t~re .~.' .'In~ a 10 year review of 94 460 admissions to Cleveland Metropolitan General Hospital, only 10 cases of splenic abscesses were found. l 2 Autopsy incidences, in studies ranging from 2840 to 16 574 autopsies performed, vary from 0.14 to 0.7%.3,4,'2We too have noted a rarity of the disease, finding only seven cases in a 10 year review of two general surgical departments in two large general hospitals. Symptoms of the disease are usually non-specific and clinical diagnosis is difficult. In the early days, diagnosis was made on strong suspicion, aided by circumstantial evidence on chest or abdominal radiographs or barium studies (Fig. 2).' Technetium ( V c ) scans and ultrasonography were the investigations of choice in the 1 9 7 0 ~ . ~ . " Computerized .'~ tomography has recently assumed the gold standard for diagnostic imaging of splenic abscesses. I4,l5 Preoperative diagnosis in all seven of the present cases was made only after computerized tomographic examination and it remains the most useful imaging modality in the diagnosis of splenic abscess. Bacterial cultures were most frequently sterile (26.6-28.7%), and cultures from blood and from the splenic abscess frequently grew different organ-
783
SPLENIC ABSCESS
In a review of culture results from 129 cases reported by various authors, between 1960 and 1970. the most common organism cultured Only four cases was Staphylococci a u r e u s (21 of Pseudomonas were found: three of Pseudomonas a e r ~ g i n o s a , ~ ' . ~and ' one of Pseudomonas
'*
pseudomallei.20
We noted an unusually high incidence of Pseudomonas in the present series, all three occurring in
middle aged males of non-Chinese ethnicity (two Malays and one Indian). This finding presents a great disparity with previously published reviews but we are unable to detect or offer any good explanation for the differences. More than half a century ago, the management of a suspected case of splenic abscess would have necessitated a diagnostic percutaneous aspirate of the abscess followed by ~ p l e n o t o m y . Mortality ~,~ then was as high as 85% in some series,21,22but was reduced significantly with the introduction of antibiotics. The use of antibiotic therapy alone, however, results in 100°/~mortality. 1 1 . 1 2 Two patients in the present series were initially treated with antibiotics alone. Though both resolved initially, relapse occurred within 6 months and splenectomy at that time resulted in one of the two patients succumbing to fulminant septicaemia.
Presently, the mortality rate of splenectomy for splenic abscesses is less than lo%, and the treatment of choice today is combined antibiotic therapy and ~ p l e n e c t o m y . ~ Four ~ ~ ~ of ' " ~the ~ five patients treated primarily by splenectomy under antibiotic cover recovered well. One patient died from septicaemia while undergoing chemotherapy for lymphoma, and the distinction between pancytopenia and OPSI as a cause, was difficult. Percutaneous drainage under CT guidance has been reported and has a success rate of more than 75% .22*23 The procedure should, however, be limited to unilocular abscess with thin fluid contents and a discrete wall without septations. It has been suggested that this treatment be performed in the critically ill where surgery is contraindicated or in young patients where splenic preservation is desirable.24.25Splenectomy is required should percutaneous drainage fail. l4 Percutaneous drainage was not possible in this series because of multiple abscesses in five, perforation in one (case 7), and the need for splenectomy for foreign body in the last (case 1 ) . Though the expertise for percutaneous drainage under CT guidance was available in the two centres, we were unable to find suitable patients, and this may be the main limitation to making percutaneous drainage the treatment of choice for splenic abscesses. In conclusion, pre-operative clinical diagnosis of splenic abscess is difficult but greatly facilitated by CT scan, and splenectomy combined with antibiotics is curative in the majority of cases.
References
Fig. 2. Barium meal showing extrinsic compression of the fundus and body of the stomach from the left (case 7 # HQL).
I . HIPFWRATES ( 1849) Oruvrrs Completes D'Hippocrutr (Eds Littre'E Libraire de 1 ' ) . vol. 6, pp. 155-230. Acadernie Nationale de Medicine, Paris. 2. ELTINGA. W. (1915) Abscess of the spleen. Ann. Surg. 62, 182-92. 3. BILLINGS A. E. (1928) Abscess of the spleen. Ann. Surg. 88, 416-28. 4. REIDS . E. (1954) Abscess of the spleen. A m . J . Surg. 88, 912-17. J . E. (1974) 5. GADACZT., WAY L. W . & DUNPHY Changing clinical spectrum of splenic abscess. Am. J . Surg. 128, 182-7. 6. COHEN M. A . A , , GALERA M . I . , Rulz M. & LA CALLE J . P. JR (1990) Splenic abscess. World J . Surg. 14, 513-17. T. K . P. & BALUM. 7. RAMAKRISHNAN M. R., SARATHY ( 1 987) Percutaneous drainage of splenic abscess: Case report and review of literature. Puediarrics 79, 1029-3 1. 8 . CHUNC. H . , RAFFM. J. & CONTRERAS L. (1980) Splenic abscess. Medicine 59, 50-65. 9. SARRM. G . & ZUIDEMA G. D. (1982) Splenic abscess - presentation, diagnosis and treatment. Surgery 92,480-5. 10. FAUGHT W . E . , GILBERTWN J . J . & NELSONE. W.
784
( 1989) Splenic abscess: presentation, treatment options and results. Am. J . Surg. 158, 612-14. 11. SIMSON J . N. L. (1980) Solitary abscess of the spleen. Br. J . Surg. 67, 106-10. J. D. & LANKERANI M. R. (1976) Splenic 12. CHULAY abscess: Report of 10 cases and review of the literature. Am. J . Med. 61, 513-22. D. M. & MCILRATH D. C. 13. LINOSD. A., NAGORNEY (1983) Splenic abscess: the importance of early diagnosis. Mayo Clin. Proc. 58, 261-4. 14. VAN DEK LAANR. T., VERBEETEN B . JR, SMITS N. J. & LUBBERS M. J. (1989) Computed tomography in the diagnosis and treatment of solitary splenic abscesses. J . Compui. Assist. Tomogr. 13, 74. 15. GRANTE., MERTENS M. A. & MASCATELLO V. .I. (1979) Splenic abscess: comparison of four imaging methods. AJR 132,465-6. 16. PAWAR S., KAYC. J. & GONZALEZR. (1982) Sonography of splenic abscess. AJR 138, 259-62. 17. PICKLEMAN J. R., PALOYAN E. & BLOCKG. E. (1970) The surgical significance of splenic abscess. Surgery 68,287-93.
001ET AL
18. KOLAWOLE T. M. & BOHRER S. P. (1973) Splenic abscess and the gene for hemoglobin S. Am. J . Roentgenol. Radium Ther. Nucl. Med. 119, 175-89. 19. MCSHERRY C. K. & DINEEN P. (1962) The significance of splenic abscess. Am. J . Surg. 103, 618-23. 20. LEVINE S . & WHELAND T. JR (1968) Meliodosis of the spleen. Am. J. Surg. 115, 849-53. W. A ,, HARRIS S. A. & BERNARDINO M. E. 21. BERKMAN (1983) Non surgical drainage of splenic abscess. Am. J . Roentgenol. 141, 395-6. S. F., VAN SONNENBERG E. & CASOLA G. (1986) 22. QUINN Interventional radiology in the spleen. Radiology 161, 289-9 I . 23. LERNER R. M. & SPATAKO R. F. (1984) Splenic abscess: percutaneous drainage. Radiology 153, 643-5. W. C., ROBBINS A. H. & 24. GERZOFS. G., JOHNSON NABSETH D. C. (1985) Expanded criteria for percutaneous abscess drainage. Arch. Surg. 120, 227-32. 25. GLEICHS., WOLIND. A. & HERBSMAN H. (1988) A review of percutaneous drainage in splenic abscess. Surg. Gynaecol. Ohstet. 167, 21 1-16.
SPLENIC ABSCESS LONDONLUCIENP. J . OOI,*RAJ NAMBIAR,*ABURAUFF,~ PETER0. P. MACK” AND TE Lu YAP* *Department of Surgery, Singapore General Hospital and ‘Department of Surgery, National University Hospital, Singapore Isolated splenic abscess is an uncommon condition. Seven cases seen between 1980 and 1990 are reviewed. The clinical presentation is non-specific and diagnosis is usually delayed. Computerized tomography allowed for accurate diagnosis in all cases. Pseudomonas species as a causative organism is reported to be rare, but were present in three of the present cases. Antibiotic therapy alone is insufficient and splenectomy remains the treatment of choice. Key words: computerized tomography, Pseudornonas, spleen, splenectomy.
Introduction Isolated splenic abscess is a rare entity first described by Hippocrates.’ In the early reviews, splenic abscesses were due mainly to typhoid fever, malaria, dysentery and dengue Splenic abscesses secondary to appendicular abscess, salpingitis, puerperal fever, carbuncle and wounds of the skin were also described.’ In more recent times, with better control of typhoid fever. malaria and dysentery, and the introduction of antibiotics in the 1930s, a changing trend has been observed in the causative factors. Trauma, especially with the increasing popularity of splenic conservation surgery has assumed a new import a n ~ e . ~ -Immunodeficiency ’ states due to disease or during immunosuppression, blood disorders, and heroin addiction with bacterial endocarditis are being increasingly reported as predisposing causes of splenic abscesses.538-’ The aim of this paper is to highlight the nonspecific clinical presentations, the changing trends in both diagnostic and therapeutic modalities, and the presence of an unusually higher frequency of Pseudomonas species in the present series.
’
Clinical material During a 10 year period, between 1980 and 1990, a total of seven patients with isolated splenic abscesses were seen at the Departments of Surgery at the National University Hospital and Singapore General Hospital (Table 1). Correspondence: Dr Lucien Ooi, Department of Surgery, Singapore General Hospital, Outram Road, Singapore 0316. Accepted for publication 5 March 1992
There were five males and two females, with ages ranging from 20 to 62 years (mean age of 45 years). The slight male predominance and age range between 6 months and 83 years is observed in most series including the present 0ne.5~6,8-10,12313 Four were Chinese, two were Malays and one was Indian. Racial distinction has never been reported, and there was no predominance in a particular race that differed from demographic proportions. Symptoms are usually non-specific. Fever was observed in all patients. Left upper quadrant pain was observed in five of seven, with only three having left hypochondria1 tenderness as well. This is consistent with previously quoted figures of 37.6 to 39.2% for pain, and 38.2 to 42.1% for Splenomegaly was found in only four patients, and this made the clinical diagnosis of a splenic abscess difficult in most of the cases. The pre-operative diagnosis of splenic abscess in all the patients was accomplished by positive computerized tomographic (CT) scan findings of generally hypodense, usually multiple and often confluent lesions in the spleen (Fig. A preliminary ultrasound before CT scan was available in two patients and these both showed splenomegaly with multiple lesions of mixed echogenicity and anechoic features, which is diagnostic of splenic abscess.I6 Some studies have found invariable leucocytosis,6,8,’obut we have found white blood cell counts to be unreliable and not markedly raised in most situations, with values ranging between 9100 to 17 800 cells/mm3. It has been suggested that previous antibiotic therapy can cause this inconsistency, ” but it was not possible to obtain these data from many of the case records.
Left hypochondrial pain and fever
PUO*
CH
MAL
F
M
F
54
53
34
5WCM (1989)
6ABSt (1990)
7HQL 62 (1991)
Left hypochrondrial pain and loss of appetite and weight
Post laparotomy sepsis and left hypochondria1 pain
Splenomegaly
12 850 Not done
Sterile
Abscess Pseudomonas (multiple) pseudomallei
-
Not done
Hepatosplenomegaly
Sterile
Abscess Sterile (multiple)
Abscess
9 100
Abscess (single)
Sterile
Lactohacillus, Swept milleri
Sterile
Tender splenomegaly
Abscess PseudomonuA (multiple)
Not done
17 800
Malignant B cell lymphoma IIB ES
Septicaemia, ARDS
Benign cavernous haemangioma of spleen, diabetes mellitus
Post laparotomy septicaemia
None
Sterile
Tender left hypochondrium
t Patients previously reported by P. 0. P. Mack and R. Nambiar CH: Chinese; MAL: Malay; IND: Indian.
* PUO - Pyrexia of unknown origin.
CH
IND
M
Pseudomonas pseudomallei osteomyelitis
Penetrating trauma with piece of wood in spleen
Associated condition
Pseudomonas pseudomallei
NA
NA
Sterile
Abscess culture
Blood culture
Abscess Sterile (multiple)
Abscess (solitary)
Abscess (solitary)
CT result
Not done
Abwss
Not done
-
13 100
Ultrasound result
Leucocyte count (mm')
-
Fever, splenomegaly
4 SPA (1988)
CH
M
PUO*
20
Fever
Tender left upper quadrant
Signs
~
Osteomyelitis femur with recurrent left hypochondrial pain and fever
3MSH (1988)
MAL
M
52
PUO* 3 weeks after trauma 10left flank
2 MBlt (1987)
CH
Symptoms
M
Age Sex Race
I NTB 40 (1985)
Case no.
~~
Table 1. Clinical findings in patients with splenic abscess Outcome
Splenectomy Died
Splenectomy Died
Splenectomy Well
Splenectomy Well
Splenectomy Well
Splenectomy Well
Splenectomy Well
Treatment
782
001ETAL.
Fig. 1. Computerized tomography scan showing a large splenic abscess (case 2 # WCM).
Management Based on the CT scan evidence of multiple splenic abscesses, two patients were treated with antibiotic therapy alone and there was initial resolution of the disease. The disease flared up within 6 months in both cases (case 2 and 6) and splenectomy was then performed, with one patient (case 6) succumbing to overwhelming Pseudomonas pseudomallei septicaemia and adult respiratory distress syndrome (ARDS). The other recovered uneventfully. The remaining five patients underwent splenectomy under antibiotic cover. Three had multiple abscesses, one of which occurred in a spleen with a benign cavernous haemangioma (case 5). The other two were in solitary abscesses: one with a localized rupture found only at laparotomy after a previous penetrating injury to the left side 3 weeks earlier (case l), and the other in a diseased spleen complicated by lymphoma which had perforated into the stomach (case 7). Both solitary abscesses had localized rupture or perforation that was not detected by CT scan, and only discovered at the time of operation.
Results Pus for culture was obtained from all the spleens at the time of operation. Four cultures were sterile and were from patients who had all received antibiotic therapy before operation. Two of these had sterile blood cultures as well, but the other two had Pseudomonas species cultured from the blood preoperatively. This demonstrated the efficacy of the clearance of organisms by intravenous antibiotic therapy in some patients. Two patients had pre-operative sterile blood cultures, but cultures taken later from the spleen grew Pseudomonas pseudomallei in one (case 2), and Lactobacillus plus Streptococci milleri in the other
(case 7). This highlights the well known concept that intravenous therapy alone does not eradicate disease in an abscess, which always requires drainage. Culture results were unavailable in one case. All splenectomy specimens were subjected to histological examination which confirmed the diagnosis of splenic abscess in all seven cases. There were two cases with a solitary abscess and both had pathology in the spleen: one was secondary to foreign body penetration (case I); the other had lymphoma of the spleen (case 7). The remaining five had multiple abscesses: four in normal spleens and one in a benign splenic cavernous haemangioma. All patients survived splenectomy and five recovered completely without complications. Mean follow-up for these five patients was 4 years with a range between 2 and 7 years. Two patients died. Case 6 relapsed after previous resolution with antibiotic therapy alone. He succumbed to ARDS and fulminant Pseudomonas pseudomallei septicaemia despite antibiotic therapy and splenectomy . Case 7 underwent splenectomy successfully for a malignant B cell lymphoma of the spleen that had perforated into the stomach, resulting in an abscess. While under chemotherapy, she developed pancytopenia and fulminant septicaemia, which was indistinguishable from overwhelming post-splenectomy infection (OPSI).
Discussion Less than 400 cases of isolated splenic abscess have been reported in the world lite ra t~re .~.' .'In~ a 10 year review of 94 460 admissions to Cleveland Metropolitan General Hospital, only 10 cases of splenic abscesses were found. l 2 Autopsy incidences, in studies ranging from 2840 to 16 574 autopsies performed, vary from 0.14 to 0.7%.3,4,'2We too have noted a rarity of the disease, finding only seven cases in a 10 year review of two general surgical departments in two large general hospitals. Symptoms of the disease are usually non-specific and clinical diagnosis is difficult. In the early days, diagnosis was made on strong suspicion, aided by circumstantial evidence on chest or abdominal radiographs or barium studies (Fig. 2).' Technetium ( V c ) scans and ultrasonography were the investigations of choice in the 1 9 7 0 ~ . ~ . " Computerized .'~ tomography has recently assumed the gold standard for diagnostic imaging of splenic abscesses. I4,l5 Preoperative diagnosis in all seven of the present cases was made only after computerized tomographic examination and it remains the most useful imaging modality in the diagnosis of splenic abscess. Bacterial cultures were most frequently sterile (26.6-28.7%), and cultures from blood and from the splenic abscess frequently grew different organ-
783
SPLENIC ABSCESS
In a review of culture results from 129 cases reported by various authors, between 1960 and 1970. the most common organism cultured Only four cases was Staphylococci a u r e u s (21 of Pseudomonas were found: three of Pseudomonas a e r ~ g i n o s a , ~ ' . ~and ' one of Pseudomonas
'*
pseudomallei.20
We noted an unusually high incidence of Pseudomonas in the present series, all three occurring in
middle aged males of non-Chinese ethnicity (two Malays and one Indian). This finding presents a great disparity with previously published reviews but we are unable to detect or offer any good explanation for the differences. More than half a century ago, the management of a suspected case of splenic abscess would have necessitated a diagnostic percutaneous aspirate of the abscess followed by ~ p l e n o t o m y . Mortality ~,~ then was as high as 85% in some series,21,22but was reduced significantly with the introduction of antibiotics. The use of antibiotic therapy alone, however, results in 100°/~mortality. 1 1 . 1 2 Two patients in the present series were initially treated with antibiotics alone. Though both resolved initially, relapse occurred within 6 months and splenectomy at that time resulted in one of the two patients succumbing to fulminant septicaemia.
Presently, the mortality rate of splenectomy for splenic abscesses is less than lo%, and the treatment of choice today is combined antibiotic therapy and ~ p l e n e c t o m y . ~ Four ~ ~ ~ of ' " ~the ~ five patients treated primarily by splenectomy under antibiotic cover recovered well. One patient died from septicaemia while undergoing chemotherapy for lymphoma, and the distinction between pancytopenia and OPSI as a cause, was difficult. Percutaneous drainage under CT guidance has been reported and has a success rate of more than 75% .22*23 The procedure should, however, be limited to unilocular abscess with thin fluid contents and a discrete wall without septations. It has been suggested that this treatment be performed in the critically ill where surgery is contraindicated or in young patients where splenic preservation is desirable.24.25Splenectomy is required should percutaneous drainage fail. l4 Percutaneous drainage was not possible in this series because of multiple abscesses in five, perforation in one (case 7), and the need for splenectomy for foreign body in the last (case 1 ) . Though the expertise for percutaneous drainage under CT guidance was available in the two centres, we were unable to find suitable patients, and this may be the main limitation to making percutaneous drainage the treatment of choice for splenic abscesses. In conclusion, pre-operative clinical diagnosis of splenic abscess is difficult but greatly facilitated by CT scan, and splenectomy combined with antibiotics is curative in the majority of cases.
References
Fig. 2. Barium meal showing extrinsic compression of the fundus and body of the stomach from the left (case 7 # HQL).
I . HIPFWRATES ( 1849) Oruvrrs Completes D'Hippocrutr (Eds Littre'E Libraire de 1 ' ) . vol. 6, pp. 155-230. Acadernie Nationale de Medicine, Paris. 2. ELTINGA. W. (1915) Abscess of the spleen. Ann. Surg. 62, 182-92. 3. BILLINGS A. E. (1928) Abscess of the spleen. Ann. Surg. 88, 416-28. 4. REIDS . E. (1954) Abscess of the spleen. A m . J . Surg. 88, 912-17. J . E. (1974) 5. GADACZT., WAY L. W . & DUNPHY Changing clinical spectrum of splenic abscess. Am. J . Surg. 128, 182-7. 6. COHEN M. A . A , , GALERA M . I . , Rulz M. & LA CALLE J . P. JR (1990) Splenic abscess. World J . Surg. 14, 513-17. T. K . P. & BALUM. 7. RAMAKRISHNAN M. R., SARATHY ( 1 987) Percutaneous drainage of splenic abscess: Case report and review of literature. Puediarrics 79, 1029-3 1. 8 . CHUNC. H . , RAFFM. J. & CONTRERAS L. (1980) Splenic abscess. Medicine 59, 50-65. 9. SARRM. G . & ZUIDEMA G. D. (1982) Splenic abscess - presentation, diagnosis and treatment. Surgery 92,480-5. 10. FAUGHT W . E . , GILBERTWN J . J . & NELSONE. W.
784
( 1989) Splenic abscess: presentation, treatment options and results. Am. J . Surg. 158, 612-14. 11. SIMSON J . N. L. (1980) Solitary abscess of the spleen. Br. J . Surg. 67, 106-10. J. D. & LANKERANI M. R. (1976) Splenic 12. CHULAY abscess: Report of 10 cases and review of the literature. Am. J . Med. 61, 513-22. D. M. & MCILRATH D. C. 13. LINOSD. A., NAGORNEY (1983) Splenic abscess: the importance of early diagnosis. Mayo Clin. Proc. 58, 261-4. 14. VAN DEK LAANR. T., VERBEETEN B . JR, SMITS N. J. & LUBBERS M. J. (1989) Computed tomography in the diagnosis and treatment of solitary splenic abscesses. J . Compui. Assist. Tomogr. 13, 74. 15. GRANTE., MERTENS M. A. & MASCATELLO V. .I. (1979) Splenic abscess: comparison of four imaging methods. AJR 132,465-6. 16. PAWAR S., KAYC. J. & GONZALEZR. (1982) Sonography of splenic abscess. AJR 138, 259-62. 17. PICKLEMAN J. R., PALOYAN E. & BLOCKG. E. (1970) The surgical significance of splenic abscess. Surgery 68,287-93.
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