Selected Articles from the Journal Abdominal Surgery

This article originally appeared in the Winter 2009 / Spring 2010 issue of the Journal.

An unusual case of multiple splenic abscesses following acute bacterial tonsillitis. A case report and review of literature.

Peter Ambe1
Danu Fukindoki1
Robert Hanisch1
Marc Folgilata1
Stefan Hümmler 2

1 Department of Surgery, DRK Krankenhaus
Altenkirchen, Germany

2 Radiologische Gemeinschaftspraxis
Betzdorf, Germany

Corresponding author:
Dr. Peter Ambe
Department of General and Abdominal Surgery
DRK Klinikum Westerwald
Leuzbacher Weg 21
57610 Altenkirchen, Germany
Tel: 0049 2681 885120
Fax: 0049 2681 889994
Email: ambepeter@hotmail.com

SUMMARY
Background: Splenic abscess should be suspected in patients being treat for bacterial infections, who present with a sudden palpable tenderness in the left upper quadrant. An abdominal ultrasound is the best initial examination. The diagnosis is usually confirmed by an abdominal ct- scan.

Methods: In this paper, we report the case of a 23 year-old patient who presented with left upper quadrant pain after being treated for acute bacterial tonsillitis. An abdominal ultrasound was performed and the diagnosis was later confirmed by abdominal ct.

Results: Laparoscopic splenectomy was performed. The patient was discharged on the 8th day following surgery after being vaccinated with pneumovax® without any complications.

Conclusions: With little exceptions, splenectomy remains first-line treatment in patients with multiple splenic abcesses.

Key words: Splenic abscess; splenectomy; pneumovax®; percutaneous drainage; bacterial tonsillitis

INTRODUCTION Metastatic splenic abscesses occur following hematogenous spreading of bacteria from infective foci elsewhere in the body. Infective endocarditis, typhoid, paratyphoid, urinary tract infections, pneumonia and osteomyelitis constitute the most common sources of bacteremia.The treatment involves systemic antibiotics and abscess drainage. In this paper we report the first recorded case of metastatic abscesses to the spleen secondary to infective angina tonsillitis.

CASE REPORT
A 23 year-old man was referred to the surgical department with back pain. The pains began a week ago. Two weeks prior to referral he was diagnosed with bacterial tonsillitis which was adequately treated with amoxicillin 500 mg twice a day for over 7 days. The patient is otherwise healthy, doesn’t take any medications and has no known allergies. His past medical and surgical history were noncontributory.

On physical examination an enlarged and tender spleen could be palpated. The remaining examination was within normal limits. Laboratory investigations including ASL Titer were within normal limits. An abdominal ultrasound showed multiple hypo-echoic cystic masses in the spleen (Figure 1).

A CT scan of the abdomen was ordered (Figure 2). This confirmed the findings on ultrasound.

Some of the masses did have calcified walls mimicking ecchinococcus. A search for anti-ecchinococcus antibodies was negative.

The patient was put on i.v. antibiotics and prepared for surgery. A less invasive treatment via percutanous drainage was discussed but quickly discarded because of the large number of abscesses.

An extremely large spleen was evident on laparoscopy. This was successfully prepared laparoscopically. However the extremely large spleen could only be extracted via a larger laparotomy incision. Post surgical gram stain and culture were positive for streptococcus. The post surgical course was uneventful. Eight days after surgery the patient was vaccinated and discharged.

Figure 1. Ultrasound film showing multiple abscesses in the Spleen.

Figure 2. A CT scan showing multiple abscesses in the spleen

COMMENTS
Splenic abscess is a well recognized entity requiring prompt intervention. Patients present with abdominal pain localized to the left upper quadrant. Fever and leukocytosis are generally present. Left sided chest finding could include pathologic sound on auscultation and radiologic signs of infiltration and pleural effusion1. Splenic abscesses usually originate from other infective sites in the body. This is particularly true for immune-compromised patients.Metastatic abscess to the spleen secondary to infective angina tonsillaris in a healthy adult is extremely rare. A review of literature was unsuccessful, so that we consider this to be the first recorded case of multiple splenic abscesses following infective angina tonsillaris.

The diagnosis of splenic abscess is straight forward. An abdominal ultrasound shows cystic structures in the spleen with mixed echo qualities2. The diagnosis is verified by an abdominal CT scan with i.v contrast enhancement3. The treatment consists of a broad spectrum i.v. antibiotic followed by abscess evacuation. In instable patients and in cases of simple abscesses a percutaneous drainage is favored4. This is less invasive and the spleen is preserved. In all other cases surgery is required5. This is true in this case due to the large number of non-communicating abscesses.

Overwhelming post splenectomy sepsis is the most feared complication of splenectomy. For this reason some surgeons prefer a selective resection of the involved splenic segment6. This complication however has become rare since the introduction of pneumovax®, a vaccine against the bacteria associated with post splenectomy sepsis. Secondly a segment resection of the spleen could be complicated by extensive bleeding, which could be lethal for the patient.

RECOMMENDATIONS
Although metastatic abscess to the spleen is rare, it comprises a potentially lethal disease warranting a rapid diagnosis and treatment. This should be considered in patients with infective foci who present with left upper quadrant pain in association with fever and left lung pathologies.Ultrasound or ct guided percutaneous drainage has been shown to be just as effective as splenectomy and is the treatment of choice in patients with uncomplicated or solitary abscesses. Splenectomy is recommended for complicated and multiple abscesses.

An alternative to splenectomy is a selective segment resection. This procedure could be complicated by excessive hemorrhage. Because of its central role the cell mediated immunity, this organ preserving procedure is strongly recommended in immune incompetent patients. Thus the indication for splenectomy in such patients should be reconsidered.

Overwhelming post splenectomy sepsis is a well recognized complication following splenectomy. This consist of septic infections caused by encapsulated bacteria, most commonly haemophilus influenzae and streptococcus pneumoniae. This complication is however preventable in a vast majority of the cases via post surgical vaccination with. Pneumovax® is a safe vaccine which is injection subcutaneously 2 weeks after surgery. Immune incompetent patients profit more from spleen preserving procedure like percutaneous drainage or selective segment resection.

REFERENCES

1. Chulay JD., Lankerani MR. Splenic abscess: Report of 10 cases and review of the Literature. Am J Med 1976;61:513-22

2. Goske RM., Wood BP., Lerner RM. Spenic abscess diagnosed by ultrasound in the pediatric patient. Pediatr Radiol (1983)13:269-271

3. Piekarski J., Federle MP., Moss AA., London SS. Computed Tomography of the spleen. Radiology 1980 Jun; 135(3):683-9

4. Zerem E., Bergsland J., Skibsted L. Ultrasound guided percutaneous treatment for splenic abscesses. World J. Gastroenterol 2006;12(45):7341-5

5. Carbonell AM., Kercher KW., Mathews BD., Joels CS., Sing RF., Heniford BT. Laparoscopic splenectomy for splenic abscess. Surg Laparosc Endosc Percutan Tech. Oct. 2004;14(5):289-91

6. S. Uranues, D. Grossman, L. Ludwig, R. Bergamaschi. Laparoscopic partial splenectomy. Surg Endosc (2007) 21:57-60