Moosa, M. R.

Pillans, P. I.

University of Queensland eSpace

46 SAMT DEEL 68 6 JULlE 1985
Solitary abscess of the spleen
A report of 2 cases
M. R. MOOSA, P. I. PILLANS
Summary
Two cases of solitary abscess of the spleen are
presented and illustrate the clinical setting and
management of this potentially fatal condition. Both
patients had presumed bacterial endocarditis with
positive blood cultures yet failed to respond to
appropriate antibiotic therapy. The clue to diagnosis
was elevation of the left hemidiaphragm. Outcome in
each case was favourable after splenectomy.
S AI, Med J 1985; 68: 46-48.
Solitary abscess of the spleen is extremely rare. Between 1960
and 1980 only 34 cases were described in the world literature. 1.2
Untreated, all cases are fatal,I-4 yet with correct management
mortality is less than 10%.2 The condition is difficult to
diagnose and the clinician should have a high index of suspicion
in the presence of the appropriate clinical setting.4,5 Pain is
present in only 60% of patients and splenomegaly and a splenic
rub are even less common. Helpful signs are elevation of the
left hemidiaphragm, left pleural effusion, or basal lung infiltrate.
The diagnosis is best confirmed by computed tomography
(CT) and/or ultrasound examination. 6-8
Case reports
Case 1
A l4-year-old schoolgirl who had previously been well
presented with a 6-week history of fever and left-sided flank
pain. There were no gastro-intestinal, urinary, respiratory or
other symptoms of note. Examination revealed a pale, ill-
looking patient with a temperature of 38°C. The pulse was
collapsing and a sinus tachycardia of loo/min was present.
The blood pressure was 110/20 mmHg. The apex beat was not
displaced and a murmur of aortic incompetence was audible at
the left sternal border. There was no evidence of cardiac
failure and no stigmata of infective endocarditis. The respiratory
system was normal. The abdomen was soft, with mild tender-
ness in the left flank. The spleen was not palpable and there
was no rub. Urinalysis was negative. The erythrocyte sedimenta-
tion rate was 65 mm/1st h (Westergren), the haemoglobin
concentration 10 g/dl with normochromic normocytic indices,
and the white cell count was 13,4 x 109/1, of which 65% were
neurrophils and 30% lymphocytes. Blood cultures grew
Streptococcus sanguis sensitive to penicillin and tobramycin. An
ECG showed a sinus tachycardia of loo/min and left ventricular
Departments of Medicine and Pharmacology, University of
Cape Town and Groote Schuur Hospital, Cape Town
M. R. MOOSA, M.B. CH.B.
P. 1. PILLANS, M.B. B.CH., F.C.P. (S.A.)
Fig. 1. Postero-anterior chest radiograph demonstrating elevation
of the left hemidiaphragm.
hypertrophy. On radiography there was no cardiomegaly and
the lung fields were clear, but the left hemidiaphragm was
markedly elevated (Figs 1 and 2), with no movement demon-
strable on screening. Echocardiography revealed no vegetations.
The patient was treated with intravenous penicillin and
tobramycin, but despite adequate blood levels of antibiotic her
temperature continued to swing. Further investigation with
ultrasound (Fig. 3) and CT of the abdomen (Fig. 4) revealed a
cystic lesion in the spleen. Eight days after admission the
patient underwent splenectomy. The spleen was slightly
enlarged with multiple infarets and an area of abscess formation.
Culture specimens from the splenic abscess grew Citrobaeter
species. After surgery the patient's temperature settled
dramatically. Antibiotic therapy was continued to complete a
6-week course, and the patient made an uneventful recovery.
Case 2
A 26-year-old woman with mild mitral stenosis became
pyrexial with rigors 8 weeks after a laproscopic sterilization
performed through the umbilicus. She complained of
generalized malaise with no specific symptoms. On examination
the patient's condition was toxic and her temperature was
38°C. There were purpuric lesions on her left palm and right
big toe but no other signs of infective endocarditis. The pulse
rate was l20/min and the blood pressure 115/80 mmHg. A
murmur of mild mitral stenosis was heard with a gallop
Fig. 2. Lateral chest radiograph showing elevation of the left
hemidiaphragm.
Fig. 3. Ultrasound scan of the abdomen showing a large cystic
lesion in the spleen.
rhythm and pericardial friction rub. The respiratory rate was
26/min. Crackles were audible at the left base of the lung. The
abdomen was generally mildly tender with a wel1-healed
umbilical scar. The spleen was not palpable.
The erythrocyte sedimentation rate was 142 mm/1st h
(Westergren), the haemoglobin concentration 9,8 g/dl with
normochromic, normocytic indices, and the white blood cell
count was 17,2 x 109/1, of which 71% were neutrophils. A
chest radiograph revealed slight cardiomegaly with an elevated
left hemidiaphragm and patchy consolidation at the left base.
SAMJ VOLUME68 6JULY 1985 47
Fig. 4. eT of the abdomen showing the large splenic abscess.
Blood cultures grew Staphylococcus aureus sensitive to cloxacillin
and fucidin.
Despite treatment with cloxacil1in 2 g 6-hourly, fucidin 500
mg 8-hourly and vancomycin 300 mg 8-hourly intravenously,
the temperature continued to swing for I month. The peri-
cardial friction rub was thought to be due to a septic peri-
carditis. No vegetations were seen on the heart valves on
echocardiography, although clinically the patient was presumed
to have infective endocarditis. On screening of the diaphragm
there was decreased excursion on the left, and a Gastrografin
study showed the stomach to be displaced medial1y. Ultrasound
examination showed a defect in the lower pole of the spleen,
and a total body scan suggested a splenic abscess with a
separate infarcted area. Splenectomy was performed and a
large abscess was found in the spleen with two septic infarcts.
The patient's temperature settled but oral cloxacil1in and
fucidin therapy was continued for a further 3 weeks. She made
a complete recovery.
Discussion
The incidence of solitary abscess involving only the spleen is
0,032%.1,7 Our cases il1ustrate the close association between
splenic abscess and infective endocarditis. 1,7 At the turn of the
century typhoid, malaria and relapsing fever6,7 were the
commonest associated disease processes, but today trauma and
diabetes mellitus follow endocarditis in order of frequency. 1,5
The failure of a patient with infective endocarditis to respond
to adequate antibiotic therapy, especially if associated with an
elevated left hemidiaphragm, left pleural effusion or basal
infiltrate, should motivate the clinician to exclude splenic
abscess by CT and/or ultrasound examination. The former is
rapidly replacing technetium-99m liver and spleen scanning as
the most useful diagnostic test because of its sensitivity and
non-invasiveness..,8 The importance of these investigations
cannot be overemphasized because the clinical diagnosis is
frequently very difficult, and in 20 - 30% of cases the diagnosis
is not suspected until autopsy.2,7 Pain is present in only 60% of
patients and splenomegaly in 40%, and a splenic rub is
uncommon. 1,4
A wide range of causative organisms have been identified,
the commonest being a streptococcus (case I) or a staphylo-
coccus (case 2).2,6 The finding of different organisms in the
blood and in the abscess in case 1 is probably related to the
extreme sensitivity of the streptococcus to penicil1in and the
more fastidious nature of Citrobaeter in a polymicrobial abscess.
Correlation between results of blood cultures and culture of
48 SAMT DEEL 68 6 JULlE 1985
the abscess is approximately 75%, while the rest of the splenic
cultures are sterile.7
The treatment of choice is splenectomy, performed as soon
as the diagnosis is made. Splenotomy should be reserved for
the rare case of a massive abscess, where splenectomy may be
hazardous",5 Adequate antibiotic cover is also essential, the
duration of this being determined by the nature of the under-
lying condition, but the minimum is 10 - 14 days. In addition,
because of the subsequent risk of pneumococcal infections in
splenectomized patients the prorchylactic use of pneumococcal
polyvalent vaccine is advisable. 9, 0
The high mortality associated with solitary abscess of the
spleen is mainly due to failure to make the diagnosis. 1,2
Although the number of reported cases has increased recently/
with greater awareness of the condition and the availability of
diagnostic techniques such as abdominal CT scanning the
prognosis should improve.
We thank Miss Faldie1a Clark for typing the manuscript.
REFERENCES
I. Simpson ]NL. Solitary abscess of the spleen. Br] Surg 1980; 67: 106-110.
2. Chulay ]D, Lankerani MR. Splenic abscess: report of 10 cases and review of
the literature. Am] Med 1976; 61: 513-522.
3. Pickleman ]R, Paloyan E, Block GE. The surgical significance of splenic
abscess. Am] Surg 1974; 128: 182-187.
4. Linos DA, Nagomey DM, Mcllrath DC. Splenic abscess - the importance
of early diagnosis. Mayo Clin Proc 1983; 58: 261-264.
5. Gadacz T, Way LW, Dunphy ]E. Changing clinical speetrllm of splenic
abscess. Am] Surg 1974; 128: 182-187.
6. Gangahar DM, Delany HM. Intrasplenic abscess. Am Surg 1981; 47:
488-491.
7. Chum CH, Raff M], Contreras L et al. Splenic abscess. Medicine (Baltimore)
1980; 59: 50-65.
8. Baruch Y, Levy Y, Brook ]G, Kleinhaus U, Hashmonai M. Splenic abscess
diagnosed with the aid of computerised tomography: report of 2 cases. Br]
Surg 1981; 68: 137-138.
9. Sulivan ]L, Ochs HD, Schiffman G et al. Immune response after splenec-
tomy. Lancet 1978; H: 178-181.
10. Austrian R. A reassessment of pneumococcal vaccine. N Engl] Med 1984;
310: 651-653.
Volvulus
A case report
of the stomach
B. C. SHARMA, N. J. B. KAPALANGA, S. R. AHMED
Summary
A case of gastric volvulus with atypical clinical
features is reported. The predisposing aetiological
factors and the mechanism of genesis of this very
rare condition are discussed. The diagnosis was
established by barium meal examination after an
unsuccessful gastroscopy. The patient was success-
fully treated by emergency surgery.
S Air Med J 1985; 68: 48-49.
Stomach volvulus is rare and the exact aetiology unknown in
many cases.! Certain anatomical defects predispose to gastric
volvulus; these include ligamentous laxity, abnormal bands
and adhesions, abnormal spaces, para-oesophageal hiatus hernia,
congenital diaphragmatic hernia and eventration of the
diaphragm. 1,2 Other cases have been associated with leukaemic
splenomegaly and pancreatitis. 3 Gastric volvulus is so rare that
we have not found any reported case in the southern and
eastern African literature. In an analysis of 69 cases of bowel
obstruction in Princess Marina Hospital, Gahorone, over a 6-
'White Firm' Surgical Unit, Princess Marina Hospital,
Gaborone, Botswana
B. C. SHARMA, M.B. B.S., M.S., Senior Surgical Specialisl
N. J. B. KAPALANGA, M.D. (DAR.), Surgical Medical Officer
S. R. AHMED, M.D. (DAR), Surgical House Officer
year period, there was no case of stomach volvulus.4 We report
a case of gastric volvulus in which the patient presented with
atypical clinical features and left basal pneumonia.
Case report
A 32-year-old white man was admitted to Princess Marina
Hospital with a 6-hour history of unremitting epigastric pain
and vomiting. He reported temporary relief after each bout of
vomiting and on leaning forward. He had had a large meal the
previous day and denied overindulgence in alcohol. There was
no previous history of peptic ulcer, pancreatitis, cholecystitis,
myocardial infarction, diverticular disease or hiatus hernia.
The patient had had a similar episode of epigastric pain a
month earlier.
Physical examination revealed a normally built young man,
restless with pain. The pulse was 70/min and the blood
pressure 120/100 mmHg. There was mild epigastric tenderness,
but the abdomen was not distended. Other systems were
normal. A tentative diagnosis of acute gastritis, with a differen-
tial diagnosis of acute pancreatitis, was made. A plain erect
abdominal radiograph and a chest radiograph showed an ele-
vated left hemidiaphragm with a small left pleural effusion
(Fig. 1).
A radiological diagnosis of subphrenic abscess was made.
The patient was observed over the next 12 hours; vomiting
and epigastric pain persisted and gastroscopy was therefore
attempted but abandoned because of repeated vomiting. A
barium meal examination showed a volvulus of the stomach
(Fig. 2). Emergency laparotomy revealed a mesenterio-axial
volvulus of the stomach. The volvulus was reduced, the stomach
separated from the transverse colon by dividing the gastrocolic
omentum, and gastropexy performed. The postoperative course


Solitary abscess of the spleen - a report of 2 cases

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Solitary abscess of the spleen - a report of 2 cases

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