Isolated splenic abscess associated with enteric fever is uncommon with very few reported cases in the literature. Till recently, the condition was more frequently diagnosed at necropsy. Splenic abscess is mostly encountered solitarily rather than being multiple&nbsp;and can be fatal if untreated. Various conditions interfere with the prognosis of splenic abscess such as underlying diseases, abscess&nbsp;number and size, organism spectra, and general conditions. This unusual and potentially life-threatening disease is a diagnostic&nbsp;challenge due to its non-specific clinical picture. High index of suspicion and liberal use of imaging studies are essential for&nbsp;timely diagnosis. We report a case of enteric splenic abscess in an immunocompetent patient without any comorbidities, which&nbsp;was diagnosed by blood tests, ultrasonography, and computed tomography scan and successfully managed conservatively with&nbsp;antibiotics

Chatterjee, Suddhasatwya

Dutta, Meghna

English

Atharva Scientific Publications (E-Jounals)

Online First Eastern J Medical Sciences 1
Case Report
An uncommon twist to a common event – Isolated enteric splenic infarcts and 
abscesses
Meghna Dutta1, Suddhasatwya Chatterjee2
From, 1Post Graduate Trainee, Department of Family Medicine, 2Senior Consultant, Department of Internal Medicine and Rheumatology, Apollo 
Gleneagles Hospital Limited, Kolkata, West Bengal, India.
Correspondence to: Dr. Meghna Dutta, Department of Family Medicine, Apollo Gleneagles Hospital Limited, Kolkata - 700 054, West 
Bengal, India. E-mail: yourfriendmeghna@gmail.com
Received - 22 December 2019 Initial Review - 09 January 2020 Accepted - 24 January 2020
Typhoid fever, mainly caused by Salmonella typhi, is usually transmitted through the consumption of food, drink, or water that have been contaminated by the 
feces or urine of subjects excreting the pathogen. This disease 
typically affects the low- and middle-income countries with 
overcrowded housing and poor sanitation, or in places where 
conflicts or natural calamities have led to the compromise of 
the water, sanitation, and health-care systems. This disease has 
a high incidence in India, Sub-Saharan Africa, and Southeast 
Asia. Splenic abscess is an uncommon disease, and nearly 70% 
develops in patients with concurrent infections. The incidence 
of splenic abscess in enteric fever is low, reportedly between 
0.29% and 2%. Although hematogenous spread is the most 
common cause of splenic abscess, with the increasing prevalence 
of malignancies, organ transplantation, and immunosuppressive 
therapy, the risk of the occurrence of splenic abscesses has 
increased manyfold [1]. This is mostly seen solitary rather than 
being multiple and can be fatal if left unrecognized at an initial 
stage [2]. Patients with multiple abscesses not responding to 
percutaneous drainage (PCD) require splenectomy. Various 
studies in recent years have stressed on the dynamic clinical 
spectrum and reported that there are chances of a better outcome 
with intravenous antimicrobial therapy alone [3].
We report a rare case of enteric fever with isolated 
multiple splenic abscesses which were successfully managed 
conservatively using antibiotics.
CASE REPORT
A 19-year-old young lady presented to our outpatient department 
(OPD) with complaints of high-grade intermittent fever for 
7–8 days associated with abdominal pain, nausea, and vomiting for 
2 days. She also complained of loose stools from the past 3 days. 
As advised by her physician, she was on oral ofloxacin and other 
symptomatic treatment before her visit to our OPD. No significant 
personal and family history could be elicited. On examination, 
pulse rate was 94/min, blood pressure was 110/60 mmHg, 
temperature was 101°F, and the spleen was just palpable. Initial 
routine blood investigations only revealed leukocytosis and raised 
C-reactive protein. Widal titers were within biological limits. 
Ultrasonography (USG) of the abdomen (on day 1 of admission) 
gave the impression of mild splenomegaly and mild fatty liver 
(Fig. 1). Based on her fever of over 1-week duration, abdominal 
symptoms, and splenomegaly, she was provisionally diagnosed 
as a case of enteric fever, keeping in mind, vivax malaria, 
leptospirosis, and dengue fever as the possible differential 
diagnosis. Microbiologic investigation with blood culture showed 
the growth of S. typhi sensitive to cotrimoxazole, doxycycline, 
and ceftriaxone confirming the diagnosis of typhoid fever. The 
patient was managed with intravenous (IV) antibiotic (ceftriaxone 
2 g twice daily) for 7 days. On discharge from the hospital, she 
was advised to continue with oral antibiotics (cefixime 200 mg 
twice daily) at home for another week.
ABSTRACT
Isolated splenic abscess associated with enteric fever is uncommon with very few reported cases in the literature. Till recently, the 
condition was more frequently diagnosed at necropsy. Splenic abscess is mostly encountered solitarily rather than being multiple 
and can be fatal if untreated. Various conditions interfere with the prognosis of splenic abscess such as underlying diseases, abscess 
number and size, organism spectra, and general conditions. This unusual and potentially life-threatening disease is a diagnostic 
challenge due to its non-specific clinical picture. High index of suspicion and liberal use of imaging studies are essential for 
timely diagnosis. We report a case of enteric splenic abscess in an immunocompetent patient without any comorbidities, which 
was diagnosed by blood tests, ultrasonography, and computed tomography scan and successfully managed conservatively with 
antibiotics.
Key words: Enteric fever, Salmonella typhi, Splenic abscess, Splenic infarct
Dutta & Chatterjee Enteric splenic abscess
Online First Eastern J Medical Sciences 2
Following a week after discharge, the patient developed pain 
over the left hypochondrium with radiation to the left shoulder. On 
admission, ultrasonography and computed tomography (CT) scan 
of the abdomen were performed, which reported splenomegaly 
with multiple hypodense foci in the periphery with liquefaction 
in the larger ones, and atelectatic changes in the left lung base 
suggestive of infarcts and abscesses (Figs. 2 and 3). All other 
possible causes of splenic abscess were ruled out with relevant 
investigations such as Coombs test, human immune deficiency 
virus antibodies, and antiphospholipid antibody. With the above 
investigations, the patient was diagnosed as a case of enteric 
fever with multiple infarcts and abscesses. Prognosis and possible 
modes of management were discussed with the patient and her 
family. Surprisingly, the patient responded well to IV antibiotics 
(ceftriaxone 2 g twice daily and meropenem 1 g thrice daily for 
a month) and her clinical condition improved. She remained 
afebrile, her vitals were stable, and all her abdominal symptoms 
subsided. No other intervention was performed. Post-discharge, 
she was regularly followed up and a repeat CT of the abdomen 
after 1 month showed complete resolution of the infarcts.
DISCUSSION
Salmonella enterica subspecies enterica serovar Typhi (S. typhi), 
a human host-restricted organism, causes typhoid fever. Splenic 
abscess in itself is a rare occurrence, infection with S. typhi as 
a cause of this condition is even more rare so. The condition is 
generally associated with metastatic hematogenous infections, 
acquired immunodeficiency syndrome (AIDS), IV drug abuse, 
chemotherapy, and transplantation [4]. Due to its rarity, insidious 
onset, and vague clinical presentation, it is difficult to clinically 
diagnose enteric splenic abscess. Fever, abdominal pain, nausea, 
and vomiting are common symptoms in patients with splenic 
abscess. Nagem and Petroianu reported that 66.7% of patients 
with splenic abscess presented with a classic triad of fever, pain 
in the left hypochondrium, and splenomegaly, the same was 
observed in our case [5]. A study published in 2006 mentions 
that spleen infected with Gram-negative Bacilli has a greater risk 
of developing multiple abscesses and such patients experienced 
a higher mortality rate than patients with Gram-positive cocci 
infection and solitary abscess [6].
Multiple splenic abscesses are still extremely rare finding in 
the clinical setting encountered mostly in immunocompromised 
patients and those with underlying malignancies [7]. Our patient 
showed isolated multiple splenic abscesses which are even rarer. 
Before the advent of USG and CT, individuals with splenic abscess 
had 100% mortality rate. USG is easy to perform, inexpensive, 
and also aids therapeutically during PCD. Ultrasound is used as a 
preliminary diagnostic modality; however, it cannot discriminate 
between an abscess and an infarct in every case, making CT the 
examination of choice. On CT scan, splenic abscesses appear 
as focal areas of low attenuation with no inflammatory rim [6]. 
Often, there is an overlap in the imaging appearance alone, so the 
clinical setting is very helpful in differential diagnosis.
Various conditions interfere with the prognosis of splenic 
abscess such as underlying diseases, abscess number and size, 
organism spectra, and general conditions; however, our index 
patient was an immunocompetent lady with no comorbidities [8]. 
From a therapeutic perspective, splenectomy was once 
considered the standard treatment; however, the trend is now 
toward a conservative approach. The increased understanding 
of the possible etiology of splenic abscess and advancements 
in pharmacology has allowed the treatment to progress from 
total splenectomy to draining the abscess under the cover of 
IV antibiotics. No definite protocol for the treatment of splenic 
abscess has been set, and hence, treatment for splenic abscess is 
customized to each patient. Although the success rate of PCD has 
Figure 1: Ultrasonography on day 1 of the first admission showing 
mild splenomegaly
Figure 2: Computed tomography scan of the abdomen performed 
on day 1 of the second admission shows multiple hypodense foci in 
the periphery (yellow arrows)
Figure 3: Ultrasonography abdomen on day 4 of the second 
admission shows splenomegaly with multiple splenic infarctions
Dutta & Chatterjee Enteric splenic abscess
Online First Eastern J Medical Sciences 3
been reported between 67% and 100%, it has been observed that 
PCD may be appropriate in unilocular and peripherally located 
abscesses [4].
CONCLUSION
With its rare incidence and various misleading clinical 
manifestations, splenic abscess usually poses a diagnostic pitfall 
in the medical world. Although the confirmation of the diagnosis 
is based mostly on imaging studies, the splenic abscess should 
be suspected in a febrile patient with the left upper quadrant 
tenderness and raised white blood cell count. A high index of 
suspicion and liberal use of imaging studies are essential for 
timely diagnosis and treatment of this life-threatening condition.
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Dutta M, Chatterjee S. An uncommon twist to a 
common event – Isolated enteric splenic infarcts and abscesses. East J Med 
Sci. 2020: Epub ahead of print.


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