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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 99-102

A retrospective study of clinical, radiological, and microbial profile and outcome in patients with splenic abscess


Department of General Medicine, Jawaharlal Nehru Medical College, KAHER University, Belagavi, Karnataka, India

Date of Submission27-Oct-2020
Date of Decision29-Nov-2020
Date of Acceptance22-Dec-2020
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. Pooja Sangayya Motimath
C/O Dr. S. H. Mothimath, Plot No. 22, Azam Nagar, A.P.M.C. Road, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_84_20

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  Abstract 


Aim: This study aimed to describe the clinical, radiological, and microbiological profile; treatment; and outcome in splenic abscess. Materials and Methods: This is a retrospective study, in which fifty cases of splenic abscess that were hospitalized between January 1, 2010, and December 31, 2019, were reviewed . Results: A total of fifty cases (36 males and 14 females) were studied during this study. Majority of patients were in the age group of 24–30 years. Fever was found in 42 cases (84%), left-upper-quadrant pain in 36 cases (72%), mass per abdomen in 29 cases (58%), and rashes in 1 case (2%). These were the main clinical signs. Laboratory tests revealed leukocytosis and elevated levels of C-reactive protein (CRP) in all cases. All patients were investigated further with ultrasound and computed tomography (CT) scan. The primary focus of infection included infective endocarditis, pneumonia, pelvic abscess, retroviral disease, skin infection, and enteric fever. There was one case of epithelial cyst of the spleen that was secondarily infected and in eight cases, the etiology was not found. Treatment included surgical intervention (total splenectomy and percutaneous drainage) and conservative management with antibiotics or a combination. Both were successful. The outcome was generally favorable with the exception of two cases who succumbed to death due to septic shock. Conclusion: Abscess in the spleen is a rare condition. The clinical expression is highly polymorphic. A positive diagnosis is based on correlation of clinical features, laboratory values, and imaging. Early diagnosis with prompt suspicion is necessary to ensure timely treatment and favorable outcome.

Keywords: Abscess, antibiotics, percutaneous drainage, spleen, splenectomy


How to cite this article:
Motimath PS, Morkar DN, Shirol VV, Patil RS. A retrospective study of clinical, radiological, and microbial profile and outcome in patients with splenic abscess. APIK J Int Med 2021;9:99-102

How to cite this URL:
Motimath PS, Morkar DN, Shirol VV, Patil RS. A retrospective study of clinical, radiological, and microbial profile and outcome in patients with splenic abscess. APIK J Int Med [serial online] 2021 [cited 2021 Jun 12];9:99-102. Available from: https://www.ajim.in/text.asp?2021/9/2/99/314204




  Introduction Top


Abscess of the spleen is rare but fatal in the absence of treatment. The incidence of this condition after a large series of Western autopsy is estimated to be up to 0.14%–0.7%.[1],[2] Splenic abscesses generally occur in patients with neoplasia, immunodeficiency, trauma, metastatic infection, splenic infarct, or diabetes.[3] The incidence of splenic abscess is thought to be growing, due to the increasing number of immunocompromised patients who are particularly at risk for this disease, and also due to the widespread use of diagnostic imaging modalities such as computed tomography (CT) and ultrasonography.[4],[5],[6],[7] It is defined by the presence of one or more intraparenchymal or subcapsular collections of pus in the spleen. Its polymorphic symptomatology explains the difficulties of clinical diagnosis. The management of splenic abscess is based on medical therapy with antibiotics and splenectomy or percutaneous drainage (PCD), with good results.[8],[9],[10] However, the optimal treatment modality remains unclear. While it is recognized that PCD may be appropriate for some patients, a high failure rate (14.3%–75%) has been observed for this procedure, and surgery remains the gold standard treatment.[3],[4],[5],[6],[7],[8],[11],[12],[13],[14] Great advances in recent decades because of the development of medical imaging, early diagnosis, and appropriate adequate treatment have helped reduce the mortality and morbidity of splenic abscess greatly. The purpose of this study was to study the relevant aspects of splenic abscesses and the treatment outcomes.


  Materials and Methods Top


This is a retrospective study conducted over a period of 9 years from January 1, 2010, to December 31, 2019, in the department of general medicine at a tertiary care center, Belagavi, Karnataka, India. All patients were assessed on the basis of clinical presentation, and those with a high index of suspicion were further evaluated by imaging to confirm diagnosis. A detailed study to identify the etiology was undertaken, and various clinical and radiological findings were collected from the documented data and were analyzed as shown in [Table 1]. The treatment was either medical (antibiotic) or surgical (splenectomy) or a combination. The clinical outcomes observed were analyzed.
Table 1: Common and rare Clinical, Biochemical and radiological findings amongst patients with splenic abscess

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  Results Top


This study included 36 men and 12 women (sex ratio = 3:1); the age of the patients varied and was in the range of 21–80 years. Fever was found in 84% of cases (n = 42), the left-upper-quadrant guarding in 72% of cases (n = 36), and mass per abdomen [Figure 1] (splenomegaly) in 58% of cases (n = 29) as shown in [Graph 1].
Figure 1: Patient presenting with mass per abdomen

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Etiologies varied, with 46% of the patients having diabetes (n = 23), 16% (n = 8) having hypertension, four cases having enteric fever with pyothorax, one case having thalassemia minor with chronic liver disease, 24% (n = 12) of the cases having retroviral disease with candidal esophagitis, 10% having rheumatic heart disease with infective endocarditis, one case having tubo-ovarian mass, and one case having erythroderma secondary to airborne contact dermatitis [Graph 2]. Laboratory tests revealed leukocytosis and elevated level of CRP in all cases (100%). All patients were investigated by ultrasound and CT scan, which showed a positive diagnosis in 100% of cases. The primary site of infection was found in 48 cases which included rheumatic heart disease with infective endocarditis, lobar pneumonia, thalassemia minor, HIV, and epithelial cyst of the spleen.



Medical management alone and combination of medical and surgical management both were successful. The outcome was generally favorable and the recovery rate was 96% (n = 48) with the exception of two deaths secondary to septic shock despite medical line of management. These two cases could not be undertaken for surgery in view of irreversible shock.


  Discussion Top


In our study, fifty cases of splenic abscess were studied retrospectively. Age of the patients ranged from 25 to 80 years. Majority of the patients were male, with a male-to-female ratio of 3:1. The most common presentation was fever which ranged from a duration of 3 days to 2 weeks followed by left hypochondriac pain starting by 1–21 days of confirmed diagnosis. The various etiologies included HIV, pneumonia, pelvic abscess, epithelial cyst, enteric fever, tuberculosis of the spleen, and rheumatic heart disease with infective endocarditis. Many patients had comorbidities such as diabetes and hypertension. Most cases with positive blood culture showed infection with Staphylococcus, Streptococcus, Escherichia coli, and Brucella. Serum adenosine deaminase levels were elevated in patients with splenic tuberculosis with no evidence of pulmonary tuberculosis clinically or radiologically. Surgical resection of spleen showed multiple caseating granulomas as shown in [Figure 2] and [Figure 3]. And further histopathology confirmed the diagnosis. One patient presented with fever with mass per abdomen which was diagnosed as Ca head of the pancreas with hepatic metastasis. General physical examination revealed tachycardia, splenomegaly, and shock in the patients. Systemic examination of the cardiovascular system revealed murmurs suggestive of mitral stenosis, aortic regurgitation, and mitral regurgitation. Respiratory system examination was suggestive of pneumonia and pleural effusion. Central nervous system examination was normal in all except two who were drowsy secondary to shock. All cases showed leukocytosis, with majority having neutrophilia and a few showing lymphocytosis. Anemia and elevated erythrocyte sedimentation rate were seen in few (34% and 46%, respectively) cases. All cases were confirmed on ultrasonography/CT abdomen. All patients received empirical antibiotics which were adjusted depending on culture sensitivity report and clinical response. Nearly 80% of the patients underwent splenectomy. Only 20% were treated with antibiotics alone. Almost 96% of the patients were treated with a combination of splenectomy and empirical antibiotics and supportive care. The outcome was generally favorable with 96% recovery and 2 deaths (4%) secondary to irreversible shock despite fluid and inotropic support.
Figure 2: Post splenectomy specimen showing multiple caseating granulomas

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Figure 3: Gross specimen of spleen showing multiple microabscesses/ granulomas

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  Conclusion Top


Splenic abscess is a rare condition. The clinical expression is highly polymorphic. A positive diagnosis is based on the correlation of clinical features, laboratory values, and imaging. Early diagnosis with prompt suspicion is necessary to ensure timely treatment and favorable outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R, et al. Splenic abscess. Medicine (Baltimore) 1980;59:50-65.  Back to cited text no. 1
    
2.
Nelken N, Ignatius J, Skinner M, Christensen N. Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. Am J Surg 1987;154:27-34.  Back to cited text no. 2
    
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Ng KK, Lee TY, Wan YL, Tan CF, Lui KW, Cheung YC, et al. Splenic abscess: Diagnosis and management. Hepatogastroenterology 2002;49:567-71.  Back to cited text no. 3
    
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Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC, et al. Clinical characteristics and prognostic factors of splenic abscess: A review of 67 cases in a single medical center of Taiwan. World J Gastroenterol 2006;12:460-4.  Back to cited text no. 4
    
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de Bree E, Tsiftsis D, Christodoulakis M, Harocopos G, Schoretsanitis G, Melissas J. Splenic abscess: A diagnostic and therapeutic challenge. Acta Chir Belg 1998;98:199-202.  Back to cited text no. 5
    
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Smyrniotis V, Kehagias D, Voros D, Fotopoulos A, Lambrou A, Kostopanagiotou G, et al. Splenic abscess. An old disease with new interest. Dig Surg 2000;17:354-7.  Back to cited text no. 7
    
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Chou YH, Hsu CC, Tiu CM, Chang T. Splenic abscess: Sonographic diagnosis and percutaneous drainage or aspiration. Gastrointest Radiol 1992;17:262-6.  Back to cited text no. 8
    
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Green SL, Scott LK. Cryptogenic splenic abscess. Va Med 1986;113:164-6.  Back to cited text no. 9
    
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Ralls PW, Quinn MF, Colletti P, Lapin SA, Halls J. Sonography of pyogenic splenic abscess. AJR Am J Roentgenol 1982;138:523-5.  Back to cited text no. 10
    
11.
Carbonell AM, Kercher KW, Matthews BD, Joels CS, Sing RF, Heniford BT. Laparoscopic splenectomy for splenic abscess. Surg Laparosc Endosc Percutan Tech 2004;14:289-91.  Back to cited text no. 11
    
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Kang M, Saxena AK, Gulati M, Suri S. Ultrasound-guided percutaneous catheter drainage of splenic abscess. Pediatr Radiol 2004;34:271-3.  Back to cited text no. 12
    
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Thanos L, Dailiana T, Papaioannou G, Nikita A, Koutrouvelis H, Kelekis DA. Percutaneous CT-guided drainage of splenic abscess. AJR Am J Roentgenol 2002;179:629-32.  Back to cited text no. 13
    
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Tung CC, Chen FC, Lo CJ. Splenic abscess: An easily overlooked disease? Am Surg 2006;72:322-5.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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