Systemic infection and splenic abscess Aaron R. Belknap, MD, and Joseph Guileyardo, MD
Splenic abscess is a rare complication of systemic infection, sometimes associated with infective endocarditis. Due to its rarity and nonspecific symptoms, diagnosis is difficult. Antibiotic therapy alone is usually unsuccessful, and definitive treatment requires splenectomy, although percutaneous ultrasound-guided drainage has been successful in some patients. Abdominal computed tomography scans and ultrasound evaluation are usually diagnostic. We present two patients with treatment-resistant sepsis who were found at autopsy to have splenic abscess.
S
plenic abscess is a rare complication of systemic infection, but when present may be associated with bacterial endocarditis (1). Considering the spleen’s function of filtering blood, splenic abscess is surprisingly uncommon. In 564 patients with infective endocarditis, only 5% developed a splenic abscess (2). Due to its nonspecific signs and symptoms, the diagnosis is easily missed or delayed. Successful treatment usually requires surgical resection of the infected spleen (3). Computed tomography scans and ultrasound usually identify the splenic lesion. We present two patients with treatmentresistant systemic infections who were found at autopsy to have splenic abscesses. CASE REPORTS Case 1 A 57-year-old woman with chronic lower back pain presented to an outside hospital with a 1-month history of nausea, vomiting, and fatigue. Three to four days prior to admission, she had been bitten by her dog. The outside hospital diagnosed septic shock, and she was transferred to Baylor University Medical Center at Dallas. Blood cultures were positive for Streptococcus anginosus. She was given broad-spectrum antibiotics, vancomycin, meropenem, clindamycin, and eventually continuous penicillin infusions. However, she continued to deteriorate with intermittent fevers, distal ischemic necrosis of the hands and feet, and large cutaneous bullae. Clinically, she developed disseminated intravascular coagulopathy and suspected toxic shock. Chest x-ray suggested an acute respiratory distress syndrome. Despite therapy, she did not improve, was transitioned to comfort care, and died. Proc (Bayl Univ Med Cent) 2017;30(2):173–174
Autopsy found a puncture wound consistent with a dog bite on the left index finger. Ischemic necrosis of the distal extremities and acute lung injury were also confirmed. An unexpected finding was a subcapsular splenic abscess measuring 3.5 cm in greatest dimension with associated organizing splenic vein thrombosis. She died from multisystem organ failure due to a systemic inflammatory response syndrome associated with septic shock, likely due to Streptococcus anginosus. Case 2 A 52-year-old man with severe obesity, sleep apnea, and atrial fibrillation presented to an outside hospital for atrial ablation therapy. Following this procedure, he developed a bloody pericardial effusion, pericarditis, and multiorganism bacteremia including Gemella sp., Prevotella sp., Fusobacterium nucleatum, anaerobic gram-positive cocci, and anaerobic gram-negative coccobacilli. Culture of the pericardial effusion was positive for Propionibacterium acnes. Cranial imaging demonstrated multifocal acute and subacute hemorrhagic infarcts in addition to multiple cerebral abscesses. Following deterioration of his condition, the patient was transferred to Baylor University Medical Center at Dallas for a higher level of care. Upon arrival, intensive antibiotic therapy including central nervous system doses of vancomycin, ceftriaxone, metronidazole, and ceftazidime were given, but the source of the continuing bacteremia could not be identified, and the patient remained febrile. A few days following transfer, the patient suffered myocardial infarction with troponin levels peaking >200 ng/mL, but due to the cerebral hemorrhage, he was not a candidate for anticoagulation. He was transitioned to comfort measures and died. An autopsy confirmed multifocal organizing cerebral hemorrhages and abscesses, pericarditis, and an acute myocardial infarction. The autopsy also demonstrated multifocal splenic abscesses, with the largest measuring 6.0 cm in greatest dimension. The patient died from complications of morbid obesity From the Department of Pathology, Baylor University Medical Center at Dallas, Texas. Corresponding author: Aaron R. Belknap, MD, Department of Pathology, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246 (e-mail: [email protected]). 173
resulting in massive cardiomegaly and atrial fibrillation requiring atrial ablation with subsequent infectious complications. DISCUSSION These patients both died from bacterial sepsis associated with unrecognized splenic abscesses, and abdominal imaging, such as computed tomography or ultrasound, was not performed on either patient. The rarity of this complication, along with the difficulty in diagnosis, requires a high index of suspicion in patients with sepsis that is refractory to antibiotic therapy. However, the classic triad of fever, leukocytosis, and left upper quadrant abdominal pain is not present in many cases. The most sensitive signs are fever (90%) and leukocytosis (88%); however, these are obviously nonspecific (4). Furthermore, both patients had multiple negative blood cultures after the initial positive culture, but despite aggressive antibiotic therapy, neither improved. In general, patients with infective endocarditis or other forms of severe bacterial sepsis with abdominal pain or swelling or with prolonged fever despite appropriate antibiotic therapy should be considered for abdominal imaging in search of a splenic abscess (5). After diagnosis of a splenic abscess, standard therapy has included immediate splenectomy (2). However, recent studies have found some success with percutaneous ultrasound-guided
174
drainage, followed by splenectomy in patients who did not improve, and the reported rates of successful drainage procedures ranged from 17% to 100% (4, 6, 7). Furthermore, some of these patients had multiple splenic abscesses that were successfully treated by multiple separate drainage procedures (6). However, in view of the dire consequences of inadequate therapy for splenic abscess, further studies are needed to clarify which patients may be safely managed without splenectomy. 1. 2.
3. 4. 5.
6.
7.
Chun C, Raff M, Contreras L, Varghese R, Waterman N, Daffner R, Melo J. Splenic abscess. Medicine (Baltimore) 1980;59(1):50–65. Robinson SL, Saxe JM, Lucas CE, Arbulu A, Ledgerwood AM, Lucas WF. Splenic abscess associated with endocarditis. Surgery 1992;112(4):781– 786. Johnson JD, Raff MJ, Barnwell PA, Chun CH. Splenic abscess complicating infectious endocarditis. Arch Intern Med 1983;143(5):906–912. Green BT. Splenic abscess: report of six cases and review of the literature. Am Surg 2001;67(1):80–85. Elasfar A, AlBaradai A, AlHarfi Z, Alassal M, Ghoneim A, AlGhofaili F. Splenic abscess associated with infective endocarditis; case series. J Saudi Heart Assoc 2015;27(3):210–215. Ferraioli G, Brunetti E, Gulizia R, Mariani G, Marone P, Filice C. Management of splenic abscess: report on 16 cases from a single center. Int J Infect Dis 2009;13(4):524–530. Chou YH, Tiu CM, Chiou HJ, Hsu CC, Chiang JH, Yu C. Ultrasoundguided interventional procedures in splenic abscesses. Eur J Radiol 1998;28(2):167–170.
Baylor University Medical Center Proceedings
Volume 30, Number 2
Splenic abscess is a rare complication of systemic infection, sometimes associated with infective endocarditis. Due to its rarity and nonspecific symptoms, diagnosis is difficult. Antibiotic therapy alone is usually unsuccessful, and definitive treatment requires splenectomy, although percutaneous ultrasound-guided drainage has been successful in some patients. Abdominal computed tomography scans and ultrasound evaluation are usually diagnostic. We present two patients with treatment-resistant sepsis who were found at autopsy to have splenic abscess.
S
plenic abscess is a rare complication of systemic infection, but when present may be associated with bacterial endocarditis (1). Considering the spleen’s function of filtering blood, splenic abscess is surprisingly uncommon. In 564 patients with infective endocarditis, only 5% developed a splenic abscess (2). Due to its nonspecific signs and symptoms, the diagnosis is easily missed or delayed. Successful treatment usually requires surgical resection of the infected spleen (3). Computed tomography scans and ultrasound usually identify the splenic lesion. We present two patients with treatmentresistant systemic infections who were found at autopsy to have splenic abscesses. CASE REPORTS Case 1 A 57-year-old woman with chronic lower back pain presented to an outside hospital with a 1-month history of nausea, vomiting, and fatigue. Three to four days prior to admission, she had been bitten by her dog. The outside hospital diagnosed septic shock, and she was transferred to Baylor University Medical Center at Dallas. Blood cultures were positive for Streptococcus anginosus. She was given broad-spectrum antibiotics, vancomycin, meropenem, clindamycin, and eventually continuous penicillin infusions. However, she continued to deteriorate with intermittent fevers, distal ischemic necrosis of the hands and feet, and large cutaneous bullae. Clinically, she developed disseminated intravascular coagulopathy and suspected toxic shock. Chest x-ray suggested an acute respiratory distress syndrome. Despite therapy, she did not improve, was transitioned to comfort care, and died. Proc (Bayl Univ Med Cent) 2017;30(2):173–174
Autopsy found a puncture wound consistent with a dog bite on the left index finger. Ischemic necrosis of the distal extremities and acute lung injury were also confirmed. An unexpected finding was a subcapsular splenic abscess measuring 3.5 cm in greatest dimension with associated organizing splenic vein thrombosis. She died from multisystem organ failure due to a systemic inflammatory response syndrome associated with septic shock, likely due to Streptococcus anginosus. Case 2 A 52-year-old man with severe obesity, sleep apnea, and atrial fibrillation presented to an outside hospital for atrial ablation therapy. Following this procedure, he developed a bloody pericardial effusion, pericarditis, and multiorganism bacteremia including Gemella sp., Prevotella sp., Fusobacterium nucleatum, anaerobic gram-positive cocci, and anaerobic gram-negative coccobacilli. Culture of the pericardial effusion was positive for Propionibacterium acnes. Cranial imaging demonstrated multifocal acute and subacute hemorrhagic infarcts in addition to multiple cerebral abscesses. Following deterioration of his condition, the patient was transferred to Baylor University Medical Center at Dallas for a higher level of care. Upon arrival, intensive antibiotic therapy including central nervous system doses of vancomycin, ceftriaxone, metronidazole, and ceftazidime were given, but the source of the continuing bacteremia could not be identified, and the patient remained febrile. A few days following transfer, the patient suffered myocardial infarction with troponin levels peaking >200 ng/mL, but due to the cerebral hemorrhage, he was not a candidate for anticoagulation. He was transitioned to comfort measures and died. An autopsy confirmed multifocal organizing cerebral hemorrhages and abscesses, pericarditis, and an acute myocardial infarction. The autopsy also demonstrated multifocal splenic abscesses, with the largest measuring 6.0 cm in greatest dimension. The patient died from complications of morbid obesity From the Department of Pathology, Baylor University Medical Center at Dallas, Texas. Corresponding author: Aaron R. Belknap, MD, Department of Pathology, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246 (e-mail: [email protected]). 173
resulting in massive cardiomegaly and atrial fibrillation requiring atrial ablation with subsequent infectious complications. DISCUSSION These patients both died from bacterial sepsis associated with unrecognized splenic abscesses, and abdominal imaging, such as computed tomography or ultrasound, was not performed on either patient. The rarity of this complication, along with the difficulty in diagnosis, requires a high index of suspicion in patients with sepsis that is refractory to antibiotic therapy. However, the classic triad of fever, leukocytosis, and left upper quadrant abdominal pain is not present in many cases. The most sensitive signs are fever (90%) and leukocytosis (88%); however, these are obviously nonspecific (4). Furthermore, both patients had multiple negative blood cultures after the initial positive culture, but despite aggressive antibiotic therapy, neither improved. In general, patients with infective endocarditis or other forms of severe bacterial sepsis with abdominal pain or swelling or with prolonged fever despite appropriate antibiotic therapy should be considered for abdominal imaging in search of a splenic abscess (5). After diagnosis of a splenic abscess, standard therapy has included immediate splenectomy (2). However, recent studies have found some success with percutaneous ultrasound-guided
174
drainage, followed by splenectomy in patients who did not improve, and the reported rates of successful drainage procedures ranged from 17% to 100% (4, 6, 7). Furthermore, some of these patients had multiple splenic abscesses that were successfully treated by multiple separate drainage procedures (6). However, in view of the dire consequences of inadequate therapy for splenic abscess, further studies are needed to clarify which patients may be safely managed without splenectomy. 1. 2.
3. 4. 5.
6.
7.
Chun C, Raff M, Contreras L, Varghese R, Waterman N, Daffner R, Melo J. Splenic abscess. Medicine (Baltimore) 1980;59(1):50–65. Robinson SL, Saxe JM, Lucas CE, Arbulu A, Ledgerwood AM, Lucas WF. Splenic abscess associated with endocarditis. Surgery 1992;112(4):781– 786. Johnson JD, Raff MJ, Barnwell PA, Chun CH. Splenic abscess complicating infectious endocarditis. Arch Intern Med 1983;143(5):906–912. Green BT. Splenic abscess: report of six cases and review of the literature. Am Surg 2001;67(1):80–85. Elasfar A, AlBaradai A, AlHarfi Z, Alassal M, Ghoneim A, AlGhofaili F. Splenic abscess associated with infective endocarditis; case series. J Saudi Heart Assoc 2015;27(3):210–215. Ferraioli G, Brunetti E, Gulizia R, Mariani G, Marone P, Filice C. Management of splenic abscess: report on 16 cases from a single center. Int J Infect Dis 2009;13(4):524–530. Chou YH, Tiu CM, Chiou HJ, Hsu CC, Chiang JH, Yu C. Ultrasoundguided interventional procedures in splenic abscesses. Eur J Radiol 1998;28(2):167–170.
Baylor University Medical Center Proceedings
Volume 30, Number 2
