Splenic abscess

A 17-year-old cocaine abuser was found dead in bed. Autopsy showed signs of sepsis, splenic infarctions of different ages, and splenic necrosis with abscesses. The splenic abscesses and microabscesses in various other organs showed mixed bacterial infections (188). 

Yersinia enterocolitica Infection with Y. enterocolitica or Y pseudotuberculosis, together with haematogenous spread, may lead to a septic-typhoid course with hepatic and splenic abscess formation. Especially ulcerative colitis was frequently found to favour the formation of multiple liver abscesses. A genetic disposition is assumed in the presence of the HLA-B 27 gene. Patients with hepatic overload of iron are at special risk of Yersinia infection, since iron plays a major role in the metabolism of Yersinia. (18, 23, 28, 31, 32)... 

A spectrum of end-organ ischemic complications can occur with embolotherapy. Bowel infarction can complicate splanchnic embolization targeting bleeding or could result from inadvertent non-target embolization from an upstream source [88]. Gallbladder infarction or bile duct necrosis can complicate hepatic artery embolization or che-moembolization [89, 90]. Splenic abscess and overwhelming sepsis can occurs following splenic embolization [91]. Skin necrosis and nerve injury have been reported as a result of ethanol embolization of vascular malformations [53, 54]. Buttock muscular necrosis, buttock claudication and sexual dysfunction can occur as a result of internal iliac branch embolization, especially when distal or bilateral [92-95]. 

Splenic Abscess. Because the spleen is a highly vascularized organ, splenic abscess drainage is not (or only exceptionally) performed in most institutions. The drainage catheter (maximum diameter of 8-10 French) should pass as Httle normal splenic parenchyma as possible. 

Due to autopsy results, the incidence of splenic abscesses is estimated to be between 0.2 and 0.7% (Paris 1994). Underlying disorders are infection, emboli, trauma, recent surgery, malignant hematologic conditions, and immunosuppression. In the past, antibiotic therapy and splenectomy were the only available treatments. While mortality rates of surgical drainage range between 13 and 28% (Lucey et al. 2002), several authors... 

Thanos L etal. (2002) Percutaneous CT-guided drainage of splenic abscess. AJR Am J Roentgenol 179 629-632... 

Dettmeyer R, Schlamann M, Madea B. Cocaine-associated abscesses with lethal sepsis after splenic infarction in a 17-year-old woman. Forensic Sci Int 2004 140 210-3. 

Friction rub A respiratory friction sound above the liver is an indication of perihepatitis. This inflammation of the liver occurs in tumours, liver abscesses or bacterial perihepatitis (e. g. Fitz-Hugh-Curtis syndrome) and, in rare cases, temporarily after a liver biopsy. Perisplenic rubbing is occasionally discernible after splenic infarction. When pressure is applied to the stethoscope, the rubbing sound increases. 

Bartley, D.L., Hughes, W.T., Purvey, L.S., Parham, D. Computed tomography of hepatic and splenic fungal abscesses in leukemic children. Pediatr. Infect. Dis. 1982 1 317-321... 

It is not uncommon to find pancreatic pseudocysts after an episode of traumatic pancreatitis or chronic pancreatitis, and some pseudocysts complicating hemolytic uremic syndrome or mediastinal pseudocysts have been reported. CT will reveal a round hypodense structure with a thin or thick wall, which may enhance after contrast injection. Some of these pseudocysts can cause complications, presenting with obstruction of the common bile duct, infection, abscess formation, rupture of the pseudocyst, and can be responsible for splenic vein thrombosis or splenic hemorrhage. CT is the primary imaging tool to visualize and identify these complications (Geier et al. 1990). 

Splenic infarction and abscess has been reported in a 68-year-old woman who had received two inj ections of a solution of hjrper-tonic saline plus adrenaline 1 day apart during endoscopy on separate occasions for a bleeding gastric ulcer [66" ]. The authors recommended the use of adhesive agents, small amounts of sclerosants, and a slow injection speed for endoscopic injection therapy. 

Oida T, Mimastu K, Kawasaki A, Kuboi Y, Kano H, Amano S. Splenic infarction and abscess after endoscopic injection of hypertonic saline-epinephrine solution administered for bleeding gastric ulcer. Endoscopy 2008 40(Suppl 2) E239. 

A 56-year-old man had a bleeding ulcerative gastric tumor injected with a 50/50 mixture of enbucrilate plus hpiodol and 3 days later a CT scan showed high-density material extending from the gastric wall to the splenic hilum, near-total occlusion of the splenic artery and its branches, and a cystic mass with an air-fluid cavity in the spleen, due to splenic infarction with abscess formation [40 ]. 

Chang CJ, Su CW, Hou MC. Abdominal pain after endoscopic hemostasis of gastric tumor bleeding. Splenic infarction with abscess formation. Gastroenterology 2009 137(5) e7-8. 

Periprocedural antibiotics should be considered if end-organ ischemia is a possibility. This is more common with the small permanent agents such as PVA and in organs where there is poor collateral flow. Tissue necrosis and hematoma can lead to abscess formation. When total occlusion of the splenic artery occurs and infarction results, patients should receive the pneumococcal vaccine. They should also take prophylactic antibiotics for future procedures as if they underwent a surgical splenectomy. 

Complications of the embolization procedure include those of diagnostic angiography with the addition of aneurysm rupture, nontarget embolization, splenic infarction, abscess formation, and rarely sepsis (Fig. 8.5). Total splenic infarction can occur, which puts the patient at an increased risk of infection with encapsulated bacteria such as pneumococcus. Older literature suggests that bland splenic artery aneurysms rupture at a rate of approximately 2% [30]. However, in pregnant patients, rupture occurs in nearly every case with mortality rates for mother and fetus 70% and 95% respectively [31]. Obviously, any aneurysm in the pregnant female should be addressed since over 95% will rupture if left untreated [30, 32]. 

Fig. 8.5. a CT of the same patient from Figure 4 demonstrating a perisplenic abscess. The patient developed fever and an elevated white cell count one week after embolization. Note arterial perfusion of a splenic remnant medial to the abscess, b CT image inferior to that of a demonstrating the coils near the splenic hilum. Collateral flow to the spleen despite complete occlusion of the splenic artery exists, c Inferior aspect of the abscess distinguishing kidney from the residual spleen. (Courtesy of James R. Duncan, MD)... 

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