A 50-Year-Old Man With Left Upper Quadrant Pain and Pyrexia (printer-f...

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Author(s)
Anusuya Mokashi, MD

Anusuya Mokashi, MD, Department of Diagnostic Radiology Resident, Staten Island University Hospital, NY, NY Disclosure: Anusuya Mokashi, MD, has disclosed no relevant financial relationships.

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A 50-Year-Old Man With Left Upper Quadrant Pain and Pyrexia (printer-f...

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Dhana Rekha Selvaraj, MD, MBBS

Dhana Rekha Selvaraj, MD, MBBS, Department of Medicine Rotator, Westchester Medical Center, New York Medical College, Valhalla, NY Disclosure: Dhana Rekha Selvaraj, MD, has disclosed no relevant financial relationships.
Chandrasekar Palaniswamy, MD

Chandrasekar Palaniswamy, MD, Department of Medicine Resident, Westchester Medical Center, New York Medical College, Valhalla, NY Disclosure: Chandrasekar Palaniswamy, MD, has disclosed no relevant financial relationships.
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia Disclosure: Ali Nawaz Khan, FRCS, FRCP, FRCR, has disclosed no relevant financial relationships.
Klaus L. Irion, MD, PhD

Klaus L. Irion, MD, PhD, Consultant Radiologist, Department of Radiology, The Pennine Acute Trust, UK Disclosure: Klaus L. Irion, MD, PhD, has disclosed no relevant financial relationships.

Posted: 03/16/2009; Updated: 03/17/2009 Background

A 50-year-old man presents to the emergency department (ED) with a 2-day history of fever and persistent left upper quadrant pain resulting from a minor blow to the left upper quadrant. Three days before presentation, the patient was playing in his weekly soccer game when he was Figure 1. Figure 2. Figure 3. Figure 4. kicked in his left upper quadrant. Initially, he only (Click to enlarge) (Click to enlarge) (Click to enlarge) (Click to enlarge) felt some soreness in the affected region of his abdomen; however, the pain persisted and, on the following day, it intensified and was accompanied by a recorded fever of 102F (38.9C). This episode of worsened pain occurred while the patient was trying to relax and watch a football game on the television. He cannot cite any alleviating or aggravating factors, and he has not noted any changes in his bowel movements. The patient does not have any nausea, vomiting, melena, or hematochezia. His past medical history is significant only for gastroesophageal reflux disease (GERD), for which he takes esomeprazole. The patient has not taken any medication for the abdominal pain. The physical examination reveals a physically fit white male in no acute distress. His weight is 180 lb and his height is 5'10". His oral temperature is 102.3F (39.1C). His blood pressure is 130/80 mm Hg, his pulse is regular at 85 bpm, and his heart sounds are normal, without any murmurs, rubs, or gallops. The patient's respirations are 14 breaths/min and unlabored. His lungs are clear to auscultation. The examination of the head and neck is unremarkable. The abdominal examination reveals tenderness in the left upper quadrant accompanied by slight muscle guarding; no rebound or rigidity is noted, and no discrete masses are palpated. Mild edema of the soft tissues in the left upper quadrant is observed. Costovertebral tenderness is absent. The bowel sounds are normal, and no organomegaly is found. The rectal examination reveals no masses, and the fecal occult blood test is negative. The laboratory analysis includes a complete blood cell count (CBC) with differential, a complete metabolic panel, a coagulation

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profile, a lipase test, and a urine analysis. The CBC reveals an elevated white blood cell (WBC) count of 20.0 103/L (20.0 109/L), with a left shift. The rest of the laboratory analysis was within normal limits, with a creatinine of 1.2 mg/dL (106.1 mol/L), glucose of 90 mg/dL (4.9 mmol/L), prothrombin time (PT) of 12.1 seconds, partial thromboplastin time (PTT) of 28.5 seconds, and lipase of 85 units/L. The urine analysis is negative for bacteria and has a specific gravity of 1.010, with 1.2 WBCs per high-powered field, 0.9 red blood cells per high powered field, and no casts. It is noted in the record that the patient had a negative HIV test approximately 4 months ago, and he had a screen for sickle cell disease that was also negative. A computed tomography (CT) scan is performed (see Figures 1-4).

What is the diagnosis? Hint: It is a known complication of splenic trauma. Splenic hemorrhage Splenic abscess Splenic necrosis Splenic emboli

Discussion

Sections of the CT scan show a low-density lesion within the spleen, with multiple areas of air density highly suggestive of a splenic abscess with gas forming organisms. Splenic abscess is a rare clinical entity. A high index of suspicion is required for the diagnosis because Figure 1. Figure 2. Figure 3. Figure 4. the clinical presentation is often nonspecific. (Click to enlarge) (Click to enlarge) (Click to enlarge) (Click to enlarge) Prompt diagnosis and early management are essential to prevent the high mortality associated with this disease. Autopsy studies have suggested an incidence of 0.14-0.7%, with a slight male predominance.[1,2] The estimated incidence in a clinical setting is 0.012% per 1000 hospital admissions per year. All age groups may be involved.[3] The mortality rate is as high as 47% and, in untreated patients, it reaches 100%.[4] Alcoholics, diabetics, and immunosuppressed individuals, including patients with acquired immunodeficiency syndrome (AIDS), are at risk. Predisposing events to splenic abscess include splenic infarction (which can result from sickle cell anemia, leukemia, or therapeutic embolization) and splenic trauma from the infection of devitalized tissue.[4] In this patient, in addition to the serologic tests noted above, screenings for lymphoma, immunoglobin, and hydatid cysts were all negative. The etiology was thought to be secondary to the splenic trauma that the patient had recently suffered. The route of infection for the development of a splenic abscess can be hematogenous, stemming from a distant focus, or it can be contiguous, spreading from the adjacent organs and peritoneal spaces. Infectious endocarditis is considered to be the most common source of infection, accounting for 10-20% of associated splenic abscesses.[5] Other sources of infection include typhoid, malaria, urinary tract infections, osteomyelitis, otitis media, pneumonia, appendicitis, and pelvic infections. Infections in contiguous areas, such as pancreatitis and pancreatic adenocarcinoma, retroperitoneal and subphrenic abscesses, or diverticulitis, may extend to involve the spleen. Polymicrobial flora is seen in 50% of cases. Bacterial splenic abscesses are most commonly caused by Staphylococcus, Streptococcus, Enterococci, Salmonella, Escherichia coli, Klebsiella, Proteus, and Pseudomonas.[4] Mycobacterial and Candida infections are usually encountered in

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immunocompromised patients. In endemic areas, Burkholderia pseudomallei is a common etiologic agent. Unifocal abscesses usually result from bacterial etiology, whereas fungal and mycobacterial infections give rise to miliary or mutifocal abscesses.[6,7] The classical triad described for splenic abscess includes fever (seen in more than 90% of cases), left upper quadrant pain (in more than 39% of cases), and splenomegaly (in somewhat less than 50% of cases). Any pain experienced by the affected patient can be referred to the left shoulder if the diaphragmatic pleura is involved (Kehr sign). Pleuritic chest pain aggravated by cough or forced expiration may be present (in approximately 15% of cases), as well as costovertebral tenderness. Rales and dullness in the left lung base are seen in few patients.[4] Leukocytosis, with a left shift, is seen in most of patients except, potentially, in the immunocompromised. Positive blood cultures will further support the diagnosis. Imaging plays an important role in localizing the focus of infection, differentiating the abscess from other lesions, and in guiding the treatment. Conventional radiography may be a good starting point, but a finding of abnormal soft-tissue density with or without gas is a nonspecific finding. Chest radiographs are abnormal in 80% of patients; an elevated left hemidiaphragm, pleural effusion, or lower lobe atelectasis may be seen. An abnormal soft-tissue density or gas pattern is identified in the left upper quadrant in up to 35% of patients. Plain radiographs of the abdomen may show abnormal soft-tissue density in the left upper quadrant and the presence of gas; however these findings are often nonspecific (as stated earlier).[4] Ultrasonography is the preferred initial imaging modality because it has good sensitivity, is easily available, is noninvasive, and is portable. The sonographic appearance of splenic abscesses includes unilocular or multilocular, hypoechoic or anechoic lesions, which may contain septations and internal debris.[7] Color Doppler studies can help in differentiating abscesses from neoplasms, as abscesses typically have an avascular appearance.[8] CT scanning is considered more accurate for making a definitive diagnosis. On CT scans, the lesions appear hypodense, and they show peripheral enhancement on intravenous contrast, which helps in differentiating the abscesses from cysts and hematomas.[9] Infection with Candida can give rise to "bull's eye" lesions, which are seen as hypoattenuating foci with central cores of hyperattenuation.[7] In magnetic resonance imaging (MRI), the lesions are hypointense on T1-weighted images and isointense or hyperintense on T2-weighted images. Radionuclide-labeled studies employing technetium-99mlabeled leukocytes can be used to differentiate foci of acute infection from splenic infarcts; infections will show increased uptake, whereas infarcts are seen as focal defects.[10] The presence of a gas or fluid level within the lesion (in the absence of prior interventions or biopsy procedures) is considered pathognomonic of pyogenic abscess [7]; however, there are few case reports demonstrating the presence of gas caused by a nonsuppurative infarction of spleen. The main differentiating feature indicating a nonsuppurative infarction rather than an infection is the presence of gas in the arteries, giving rise to linear air collections seen on CT scans.[11,12] The administration of empirical antibiotic therapy is the initial management in all patients with splenic abscesses. In immunodeficient patients, the possibility of fungal and mycobacterial abscesses must also be considered. Therapy is switched over to specific antibiotics once cultures and sensitivity reports are obtained. Although splenectomy is associated with a significant mortality rate and can further compromise the immune status of the patient, surgical drainage and splenectomy have been the traditional treatment. Ultrasonography-guided and CT-guided percutaneous aspiration and drainage procedures under antibiotic cover are being increasingly employed, with good success rates.[9,13] In a retrospective study of 39 patients with splenic abscess, the survival rates for splenectomy, open drainage, medical therapy, or percutaneous drainage were respectively 94%, 50%, 70%, and 100%.[3] An initial diagnostic aspiration is performed during percutaneous drainage to confirm the diagnosis, and the pus obtained is used for microbiological assessment. Following this, an 8F or 10F pigtail catheter is introduced using the trocar technique and placed in the abscess cavity. The patient is followed up with clinical assessment and imaging for the residual abscess, and the catheter is removed once resolution is confirmed. The usual drainage period is 7-14 days. Complications associated with percutaneous drainage of splenic abscesses include hemorrhage, pleural empyema, pneumothorax (transpleural catheterization), and fistula formation. Multilocular abscesses with thick septations and necrotic debris, phlegmonous, poorly defined cavities, and multiple collections are less amenable to percutaneous drainage and should be considered for surgical management.[9] Percutaneous imaging-guided aspiration and drainage under antibiotic cover should be considered if the topography and nature of the abscess allow for it. Surgery can be reserved for cases not amenable to percutaneous drainage, as well as for cases in which catheter drainage has failed. Diagnostic aspiration using either ultrasonography or CT scanning as a guide is quite useful in establishing the diagnosis, as well as in obtaining specimens for culture (in order to guide the choice of antimicrobial therapy).

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The patient in this case improved after treatment with broad spectrum antibiotics, and he underwent a percutaneous guided aspiration, with subsequent placement of a drain into the abscess collection. The culture results of the aspiration yielded pansensitive E. coli. He was switched to a more targeted antibiotic regimen and, after a follow-up ultrasound, showed resolution of the abscess collection. He was discharged to home with the drain in place and with oral antibiotics. On follow-up at 2 weeks after discharge, he was noted to be doing well, and the drainage tube was removed.

Which of the following choices is the preferred initial imaging modality when considering splenic abscess? Ultrasonography Computed tomography (CT) scan Chest radiography Abdominal radiography Abdominal magnetic resonance imaging (MRI) Which of the following features are always present in patients with splenic abscess? Fever Leukocytosis Abdominal pain Splenomegaly None of the above

For more information on splenic abscesses, see the eMedicine article Splenic Abscess (in the General Surgery section).

1. 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. Abstract 2. 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. Abstract 3. Phillips GS, Radosevich MD, Lipsett PA. Splenic abscess: another look at an old disease. Archives of Surgery. 1997;132:1331-5. Abstract 4. Losanoff JE, Basson MD. Splenic Abscess. eMedicine, May 21, 2007 5. Green BT. Splenic abscess: report of six cases and review of the literature. Am Surg. 2001;67:80-5. Abstract 6. Ng CY, Leong EC, Chng HC. Ten-year series of splenic abscesses in a general hospital in Singapore. Ann Acad Med Singapore. 2008;37:749-52. Abstract 7. Paterson A, Frush DP, Donnelly LF, Foss JN, O'Hara SM, Bisset GS 3rd. A pattern-oriented approach to splenic imaging in infants and children. Radiographics. 1999;19:1465-85. Abstract 8. Peddu P, Shah M, Sidhu PS. Splenic abnormalities: a comparative review of ultrasound, microbubble-enhanced ultrasound and computed tomography. Clin Radiol. 2004;59:777-92. Abstract 9. Thanos L, Dailiana T, Papaioannou G, Nikita A, Koutrouvelis H, Kelekis DA. Percutaneous CT-guided drainage of splenic abscess. Am J Roentgenol. 2002;179:629-32. 10. Vijayakumar V, Briscoe EG. Usefulness of Tc99m HMPAO labeled leukocyte scintigraphy in differentiating splenic abscess from infarct. The Internet Journal of Nuclear Medicine. 2006;3. Available from: ISPUB.com: The Internet Journal of Medicine. Available at: http://www.ispub.com/journal/the_internet_journal_of_nuclear_medicine /volume_3_number_1_36/article/

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usefulness_of_tc99m_hmpao_labeled_leukocyte_scintigraphy_in_differentiating_splenic_abscess_from_ infarct.html 11. Levy JM, Wasserman PI, Welland DE. Nonsuppurative gas formation in the spleen after transcatheter splenic infarction. Radiology. 1981;139:375-76. Abstract 12. Barzilai M, Schlag-Eisenberg D, Peled N, Bitterman A. Noninfectious gas accumulation in an infarcted spleen. Dig Surg. 2000;17:402-4. Abstract 13. Chou YH, Hsu CC, Tiu CM, Chang T. Splenic abscess: sonographic diagnosis and percutaneous drainage or aspiration. Gastrointest Radiol. 1992;17:262-66. Abstract Contents of A 50-Year-Old M an With Left Upper Quadrant Pain and Pyrexia [/viewprogram/19174] 1. A 50-Year-Old Man With Left Upper Quadrant Pain and Pyrexia [/viewarticle/589676]

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