Splenic Abscess Detection

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Journal of Diagnostic Medical Sonography

28(4) 168172

The Author(s) 2012

Reprints and permission: http://www.

sagepub.com/journalsPermissions.nav

DOI: 10.1177/8756479312442110

http://jdms.sagepub.com

Case Studies

Abscess of the spleen is not a routinely seen finding. A

review of the literature shows that only 500 to 600 cases

have ever been reported internationally.1The pathogen-

esis of splenic infections responsible for splenic abscess

is typically defined by five categories: (1) metastatic

hematogenous infection, including intravenous (IV)

drug use; (2) hemoglobinopathy; (3) immune systemsuppression secondary to chemotherapy or human

immunodeficiency virus; (4) trauma; and (5) contiguous

site of infection.25The most frequent agent of splenic

abscess is an infection with gram-positive cocci domi-

nated by Enterobacteriaceae. When gram-negative

bacilli are the causative agent of the infection, the most

frequently represented are Klebsiella pneumoniae and

Escherichia coli.6Most splenic abscesses are caused by

a source of infection originating from outside of the

affected organ. Sengupta and Mukhergi7 determined

that 70% of splenic abscesses were caused by infectious

sources external to the spleen such as amoebic dysen-tery, peritonsillar abscess, bacterial endocarditis, lung

abscess, appendicitis, or pneumonia. An additional 15%

were related to direct trauma to the spleen, and 10%

were a result of sepsis.

We present a case of splenic abscess secondary to uro-

sepsis, an infection of the urogenital tract that occurs

when bacteria are introduced, which was detected and

monitored by sonography. In this case, a prior medical

procedure, a transrectal sonography-guided prostate

biopsy, allowed E coli to travel to the spleen via the

bloodstream.

Case Report

A man in his mid-50s underwent a transrectal sonography-

guided prostate biopsy due to elevated prostate-specific

antigen (PSA). Bactrim, a preparation of sulfamethoxazole

and trimethoprim, had been given for perioperative pro-

phylaxis. Four days after the procedure, the patientreturned to the emergency room (ER) with a high-grade

fever and abdominal pain. The urinalysis was positive for

E coli, and urosepsis was determined to be secondary to

the transrectal sonography-guided prostate biopsy.

Antibiotic therapy using IV vancomycin (a drug choice

usually reserved for treatment of bacterial infections

resistant to other drugs) was administered. Nineteen days

after the procedure, the patient presented a second time

to the ER with a moderate-grade fever, chills, rigors, and

increased abdominal pain in the left upper quadrant. A

complete abdominal sonographic examination was done

using a Philips IU22 system (Koninklijke, The Netherlands)with a curved linear-array 6-MHz transducer that showed

an abscess in the spleen. The abscess was noted to be

located in the posterior spleen. Abscess volume of 90.4;

mL was calculated using the splenic volume calculation

JDMXXX10.1177/87547912442110McKi

1Diagnostic Medical Ultrasound, School of Health Professions,

University of Missouri, Columbia, MO, USA

Corresponding Author:

Elizabeth Ruzicka McKinney, BS, RDMS, University of Missouri, 3805

North Cottonwood Court, Columbia, MO 65202, USA

Email: [email protected]

Splenic Abscess Detection

and Monitoring Using Sonography

Elizabeth Ruzicka McKinney, BS, RDMS1

Abstract

The finding of a splenic abscess is rare, with only 500 to 600 cases ever having been reported internationally. Priorto the advent of sonography and computed tomography, the survival rate for an individual with a splenic abscess was

0%. Present-day real-time imaging with sonography allows for accurate diagnosis of an abscess in the spleen versusrupture, hematoma, splenomegaly, or cyst within the spleen or left kidney. Until recently, the prescribed treatment

was splenectomy. The increased understanding of splenic abscess etiology and advancements in pharmacology haveallowed the treatment to progress from surgical removal of the entire spleen to draining the abscess using fine-needle

aspiration with the use of strong broad-spectrum intravenous antibiotics.

Keywords

splenic abscess, ultrasonography, sonography, sepsis


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McKinney 169

package based on measurements of the abscess length(6.40 cm), height (6.26 cm), and width (4.30 cm)

(Figures 1 and 2). The abscess had an oval, anechoic

appearance with well-defined borders and strong poste-

rior enhancement. No inflammatory rim or isoechoic

infiltrations were detected. A peripherally inserted central

catheter line was established for the administration of

ceftriaxone, a third-generation cephalosporin antibiotic

with broad-spectrum activity against gram-positive and

gram-negative bacteria. After 14 days of 2 mg IV ceftri-

axone daily, a 91% reduction of the abscess volume was

visualized on a follow-up sonogram (Figures 3 and 4). In

addition to its smaller size (3.30 2.81 1.70 cm; 8.07mL), the abscess had also lost its anechoic appearance.

The shape was more round than oval, the borders were

not as well defined, and most of the abscess was

isoechoic to slightly hypoechoic compared with the

spleen. The location of the abscess was isolated to the

most posterior section of the spleen with only moderate

posterior enhancement. The patient continued ceftriax-

one antibiotic therapy for another 14 days, at which time

a repeat sonogram showed an additional 1% reduction in

volume. The abscess was measured as 2.92 2.23 2.14

cm (7.30 mL), with only a slight posterior enhancement

Figure 1.Long view of splenic abscess, 6.40 cm length and4.30 cm height, 15 days after diagnosis of Escherichia coliandurosepsis secondary to a transrectal sonography-guidedprostate biopsy that was done 19 days prior.

Figure 2.Transverse view of splenic abscess, 6.26 cm width,15 days after diagnosis of Escherichia coliand urosepsissecondary to a transrectal sonography-guided prostate biopsythat was done 19 days prior.

Figure 3.Long view of splenic abscess, 3.30 cm lengthand 1.66 cm height, 15 days after beginning treatment withintravenous ceftriaxone 2 mg/d.

Figure 4.Transverse view of splenic abscess, 2.81 cmwidth, 15 days after beginning treatment with intravenousceftriaxone 2 mg/d.


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170 Journal of Diagnostic Medical Sonography28(4)

(Figures 5 and 6). An additional antibiotic treatment with

augmentin, twice a day, for 28 days was prescribed. The

abscess was noted to be further reduced in size to 1.96

2.19 1.67 cm (3.73 mL), a 96% reduction of the origi-

nal abscess. Its appearance was isoechoic to the spleenwith no posterior enhancement (Figures 7 and 8). The

remaining slightly echogenic borders were the only

detectable evidence of the abscess.

Discussion

Splenic abscess is a rare finding caused by infectious

sources external to the spleen, direct trauma to the

spleen, or a result of sepsis.3,4,69They are found more

often in adults as a singular unilocular abnormality and

more often in children as multiple or multilocular abnor-

malities. Sepsis may be secondary to a variety of sources

such as endocarditis, dental infections, or, as in the

case presented, urosepsis. Sepsis will occur when an

infection leads to systemic inflammatory response

syndrome,10 the dysregulation of the inflammatory

response with excessive and uncontrolled release of pro-inflammatory mediators. It can lead to apnea, abnormal

organ function, changes in mental function, decreased

urine output, and disseminated intravascular coagulopa-

thy, forming microthrombi or other blood abnormalities.

If severe, sepsis can lead to septic shock and hypoten-

sion, hypoperfusion of one or more organs, and eventu-

ally end-organ ischemia. Early detection is essential for

a favorable prognosis, and treatment with antibiotics

should be started as soon as possible after diagnosis. For

every hour of delay in beginning treatment with the

correct antibiotic therapy, there is a correlating 7% rise

in mortality.

11

Figure 5.Long view of splenic abscess, 2.92 cm lengthand 2.14 cm height, 30 days after continued treatment withintravenous ceftriaxone 2 mg/d.

Figure 6.Transverse view of splenic abscess, 2.23 cmwidth, 30 days after continued treatment with intravenousceftriaxone 2 mg/d.

Figure 7.Long view of splenic abscess, 1.96 cm length and1.67 cm height, 28 days after oral administration of augmentinand 30 days of treatment with intravenous ceftriaxone 2 mg/d.

Figure 8.Transverse view of splenic abscess, 2.19 cm width,28 days after oral administration of augmentin and 30 days oftreatment with intravenous ceftriaxone 2 mg/d.


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McKinney 171

In the case presented, a splenic abscess was a result of

a prior medical procedure, a transrectal sonography-

guided prostate biopsy, which allowed E colito become

translocated via the bloodstream to the spleen. A potential

contributing factor in this particular case was the patients

prior history of chronic obstructive pulmonary disease

(COPD) and osteoarthritis. He was taking albuterol to

help manage the COPD, a steroid that reduces the bodys

inflammatory response. This may have reduced the abil-

ity of the patients immune system to respond to the

infection resulting from the transrectal sonography-

guided prostate biopsy.

Transrectal sonography-guided prostate biopsy is fre-

quently associated with minor complications (60%79%

of cases) but rarely with major complications that require

hospitalization (0.4%3.5% of cases).1214Early compli-

cations of transrectal sonography-guided prostate biopsy

include hematuria (70.8%) and rectal bleeding (8.3%).

Delayed complications of transrectal sonography-guidedprostate biopsy, at 3 to 7 days postbiopsy, include persis-

tent hematuria (47.1%), vague pelvic discomfort (13.2%),

hematochezia (rectal bleeding) (9.1%), dysuria (9.1%),

and hematospermia (blood in the semen) (9.1%). Even

though complications from transrectal sonography-guided

prostate biopsies are fairly common, a study by Paterson

et al12determined that only 0.23% of 4749 outpatients in

whom transrectal sonography-guided prostate biopsies

were performed between 2001 and 2006 were positive for

urosepsis. A recently tested protocol included obtaining

colon swabs from the patient prior to the transrectal

sonography procedure to determine the sensitivity of theflora.14Antibiotic prophylaxis was then selected to reflect

the organisms encountered and their susceptibilities,

decreasing the infective complications.

Sonography was an essential element in the diagnosis

and surveillance during the course of treatment in this

case of splenic abscess. Sonography allowed a noninva-

sive, rapid accurate diagnosis of an abscess in the spleen

versus possible diagnoses of rupture, hematoma, spleno-

megaly, or cyst. The ability of sonography to monitor the

splenic abscess allowed the treatment with strong broad-

spectrum IV antibiotics to run its course without the need

for splenectomy or other invasive procedures.

Conclusion

The use of imaging modalities such as sonography can

confirm or rule out a splenic abscess in a febrile patient

with left upper quadrant pain. If such an abscess is not

detected and treated with antibiotics early, it may become

severe and rapidly life-threatening with a mortality rate

up to 47%.9 The ability of sonography to monitor the

effectiveness of the antibiotics being administered has

allowed successful pharmacologic treatment of splenic

abscesses and avoided invasive procedures and splenec-

tomy with its surgical risks and long-term consequences.

Acknowledgments

The author thanks Sharlette D. Anderson, MHS, RDMS, RVT,

RDCS, and Ecaterina M. Hdeib, MA, RDMS, for their encour-

agement and help in writing and editing this case study.

Declaration of Conflicting Interest

The author declared no potential conflicts of interest with respect

to the authorship and/or publication of this article.

Funding

The author received no financial support for the research and/or

authorship of this article.

References

1. Carbonell AM, Kercher KW, Mathews BD, Joels CS,

Sing RF, Heinford BT: Laparoscopic splenectomy for

splenic abscess. Surg Laparosc Endosc Percutan Tech

2004;14:289291.

2. Phillips GS, Radosevich MD, Lipsett PA: Splenic abscess:

another look at an old disease.Arch Surg1997;132:13311336.

3. Ghidirim G, Rojnoveanu G, Misin I, Gagauz I, Gurghis R:

Splenic abscess-etiology, clinical and diagnostic features.

Chirurgia (Bucar)2007;102:309314.

4. Ulhaci N, Meteoglu I, Kacar F, Ozbas S: Abscess of the

spleen. Pathol Onocol Res2004;10:234236.

5. Sieler LA: Sonography of the spleen: a review. J Diagn

Med Sonography1987;3:69. 6. Westh H, Reines E, Skibsted L: Splenic abscesses: a review

of 20 cases. Scand J Infect Dis1990;22(5):569573.

7. Sengupta D, Mukhergi B: Ameobic abscess of the spleen.

J Ind Assoc1975;64:4547.

8. Chang KC, Chuah SK, Changchien CS, et al: Clinical

characteristics and prognostic factors of splenic abscess:

a review of 67 cases in a single medical center of Taiwan.

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9. Alvi AR, Kulsoom S, Shamsi G: Splenic abscess: out-

come and prognostic factors. J Coll Physicians Surg Pak

2008;18(12):740743.

10. Bone R, Balk R, Cerra F, et al: Definitions for sepsis andorgan failure and guidelines for the use of innovative thera-

pies in sepsis. The ACCP/SCCM Consensus Conference

Committee. Chest1992;101(6):16441655.

11. Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sep-

sis Campaign: international guidelines for management

of severe sepsis and septic shock: 2008. Crit Care Med

2008;36(1):296327.

12. Paterson RF, Buckley AR, Bryce E: TRUS and prostate

biopsy sepsis. http://www.urologyrounds.com/files/PDF/

jan-30-08.pdf


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13. Jesitus J: Prostate biopsy infections major concern

for urologist. Urol Times. 2011 May 15. http://www.

modernmedicine.com/modernmedicine/article/article-

Detail.jsp?id=722434&sk=&date%OA%09%09%09&

page=2

14. Madden T, Doble A, Aliyu SH, Neal DE: Infective com-

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Article: Splenic Abscess Detection and Monitoring

Using Sonography

Author: Elizabeth Ruzicka McKinney, BS, RDMS

Category: Abdomen

Credit: 1 SDMS CME credit

Objectives: After studying the article titled Splenic

Abscess Detection and Monitoring Using Sonography,

you will be able to:

1. Describe the common pathogenic mechanisms for

splenic infections.2. Discuss the sonographic features of a splenic

abscess.

3. Develop a sonographic follow-up protocol for

assessing the treatment of a splenic abscess.

1. Possible pathogenesis for splenic infections

resulting in splenic abscess is typically defined by

how many categories?

a. Two

b. Three

c. Four

d. Five

2. The most frequent gram-negative bacillus causing

splenic abscess is

a. Pseudomonas aeruginosa

b. Helicobacter pylori

c. Klebsiella pneumoniae

d. Escherichia coli

3. What percentage of the time are splenic abscesses

caused by infectious sources external to the spleen?a. 70%

b. 75%

c. 80%

d. 85%

4. Early sonographic features of a splenic abscess

include the following except

a. Inflammatory rim

b. Well-defined borders

c. Oval shape

d. Posterior enhancement

JDMXXX10.1177/8754791245270 JDMSMedical Sonography

JDMS CME ArticleSDMS

CME Creditavailable to SDMS Members Only

SDMS members can earn FREE SDMS CME credit by reading this approved CME

article and successfully completing the online CME test. If you are not a current SDMS

member but would like to earn SDMS CME credit, please visit www.sdms.org/

membership/ to join SDMS.

Instructions

1. Each question has only one correct answer.2. Go online to www.sdms.org/members/JDMS/ to score your test answers (SDMS membership number

required). NO JDMS CME tests will be accepted by mail or FAX.

3. You will receive your test score results immediately*if you achieve a score of 70% or better, SDMS CME

credit will be awarded.

4. Awarded CME credits are tracked in the SDMS CMETracker system. For more information about the SDMS

CMETracker system, visit www.sdms.org/members/cmetracker.asp.

*Because the correct answers will be provided after you submit your answers, only one attempt is permitted to

successfully complete the JDMS CME article test. Please verify your answers before submission.


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5. Late sonographic features of a splenic abscess

include the following except

a. Rounded shape

b. Iso/hypoechoic interior

c. Well-defined borders

d. Posterior enhancement

6. Splenic abscesses in children are most likely to

appear as a

a. Unilocular abnormality

b. Multilocular abnormality

c. Singular abnormality

d. Hyperechoic, irregular abnormality

7. If not treated early and aggressively, the mortal-

ity secondary to splenic abscess can be as high

as

a. 35%40%

b. 45%50%c. 55%60%

d. 65%70%

8. For every hour of delay in the onset of treatment

for a splenic abscess, morality increases by

a. 3%

b. 5%

c. 7%

d. 9%

9. The most common complication of sonography-

guided prostate biopsy is

a. Pelvic discomfort

b. Hematuria

c. Rectal bleeding

d. Dysuria

10. Urosepsis occurs with approximately what fre-

quency following sonography-guided prostate

biopsy?

a. 2%

b. 1%c. 0.5%

d. 0.25%

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Splenic Abscess Detection