J Clin Ultrasound 20:349-351, June 1992 CCC 0091-2751/92/050349-03 $04.00 0 1992 by John Wiley & Sons, Inc.
Case Report
Brucella melitensis Splenic Abscess: Sonographic Detection and Follow-Up Kemal Bahri Ate$, MD,* M. Enver Dolar, MD,* Mehmet Karahan, MD,? Gulay Temucin, MD,* and Leziz Onaran, MD*
Brucellosis is a disease affecting the reticuloendothelial system. Liver and spleen involvement has been reported to occur in 10% to 20% of the patients.' Splenic abscess is unusual, but it has been seen in brucellosis.2-6 We present 2 cases of splenic abscess related to Brucella melitensis, diagnosed from sonographic and bacteriological findings. CASE REPORTS Case 1
A 30-year-old woman was admitted to Yiiksek Ihtisas Hospital with complaints of fever, sweating, weakness, and weight loss for a period of one month. Vital signs showed a temperature of 38.6" C, pulse 104/min, and blood pressure 110/60 mm Hg. She appeared acutely ill. The liver was palpable 4 cm below the right costal margin. The spleen was palpable at 6 cm and was tender. Hemoglobin was 8 g/dL, white blood cell count 3400/mm3, erythrocyte sedimentation rate 68 mmh, serum glutamic- pyruvic transaminase 40 IU/L, and glutamic oxaloacetic transaminase 52 IU/L; other biochemical findings were normal. On ultrasonographic examination the liver was enlarged (vertical diameter: 15.0 cm) and its texture was normal. An anechoic lesion measuring 2.1 cm X 1.5 cm X 1.4 cm was seen near the right portal vein toward the porta hepatis. Splenic index was 32 em2. A hypoechoic intrasplenic mass with ill-defined walls, measuring 3.1 cm X 2.1 cm x 1.3 cm, was seen near the splenic hilum (Figure 1).In addition, there were
From the *Gastroenterology Department and tMicrobiology Department, Yiiksek Ihtisas Hospital, Ankara, Turkey. For reprints contact Kemal Bahri Ate$, MD, Gastroenterology Department, Yiiksek Ihtisas Hospital, Ankara, Turkey.
innumerable small (5 mm to 6 mm), oval-shaped, scattered anechoic lesions. The agglutinin titer for Brucella was 1/1280. B . melitensis grew in blood cultures. Echocardiography was normal. The patient was thought t o have hepatic and splenic abscesses related to B . melitensis. Tetracycline (2 g/day) and streptomycin (1g/day) therapy was started. Her symptoms disappeared in 6 days. Ultrasonographic followup revealed that the hepatic and splenic masses continued to become smaller. The therapy was continued for 4 weeks. All lesions disappeared 6 weeks later. She has remained in good health for 11 months. The liver and spleen returned to normal size. Case 2
A 50-year-old man was admitted to Yiisek Ihtisas Hospital with fever, sweating, and pain in the left upper quadrant for three weeks. Physical examination revealed a temperature of 38.7" C, pulse 96/min, and blood pressure 130180 mm Hg. The spleen was 4 cm below the left costal margin and tender. Laboratory findings were hemoglobin 10.3 g/dL, white cell count l1200/mm3 and erythrocyte sedimentation rate 65 mmh, serum glutamic- pyruvic transaminase 60 IU/L, and serum glutamic oxaloacetic transaminase 66 IU/L. The other biochemical results were within normal limits. Ultrasonographic examination revealed an enlarged spleen, multiple intrasplenic, small anechoic lesions and a 5.6 cm x 3.3 cm x 2.5 cm subcapsular anechoic lesion (Figure 2). Echocardiography was normal. The agglutinin titer for Brucella was 1/1280. Three blood cultures yielded B . melitensis. The patient was placed on tetracylin (2 g/day) and streptomycin (1g/day) therapy, and was discharged after satisfactory improvement. On ul349
350
CASE REPORT: ATEQ ET AL.
FIGURE 1. Oblique scan of the spleen showing a hypoechoic mass (arrowheads) near the hilum.
trasonographic examination all small lesions had disappeared, but the subcapsular lesion was still present 4 weeks later. Rifampicin (600 mgl day) was started and continued for 4 weeks. The subcapsular splenic collection disappeared by the end of this therapy. He has been symptom free for 10 months.
DISCUSSION
Brucellosis is a classical zoonotic disease. Brucella melitensis is the most common cause of human brucellosis. After the entry of brucella organisms into the human body, they pass through the lymphatics to the regional lymph nodes.
FIGURE 2. Longitudinal sonogram of the spleen showing subcapsular splenic abscess (arrowheads). JOURNAL OF CLINICAL ULTRASOUND
B R UCELLA MELITENSIS SPLENIC ABSCESS
351
3. Mc Garity WC, Sarafin D: Brucellosis: Indication They then invade the blood stream and localize for splenectomy. Am J Surg 115:355-363, 1968. in body organs that are rich in reticuloendothe4. Dubbins FA: Ultrasound in the diagnosis of lial tissue, such as lymph nodes, bone marrow, splenic abscess. Br J Radiol 53:489-491, 1980. liver, and spleen.' Caseation necrosis and ab5 . Nelken N, Ignatins J , Shinner M, Christensen N: scess formation occurs in infections caused by B. Changing clinical spectrum of splenic abscess. A m suis and is less frequently seen in infections due J Surg 154:27-33, 1987. to other Brucella species.'r7*'Brucella suis is the 6. Chulay JD, Lankeram MR: Splenic abscess: Remain species isolated from liver and spleen abport of 10 cases and review of the literature. Am J scesses.' A review of the literature failed to idenMed 61513-521, 1976. tify any prior report of B. melitensis-related 7. Mittelstaed CA, Partain CL: Ultrasonic pathologic spleen abscesses. Only 1 patient with a B . classification of splenic abnormalities: Gray scale patterns. Radiology 134:697-705, 1980. melitensis-related cerebellar abscess has been re8. Spink WW: Suppuration and calcification of the p~rted.~ liver and spleen due to long standing infection The conventional radiologic methods are nonwith Brucella suis. N Engl J Med 257:209-210, specific in the diagnosis of splenic 1957. The sensitivity and specificity of the splenic 9. Gaytan JA, Baqueiro HO, Maza MD: Brucella scanning with 9 9 m Tsulphur ~ colloid and gallium melitensis cerebellar abscess. J Infect Dis 67 citrate are 10w.ll-'~Scaning with indium-111 1601730-731, 1989. labeled leucocytes and computed tomography are 10. Miller FJ, Rothermel FJ, O'Neil MT, Schochat JJ: more valuable. l4,I5 However, all these diagnostic Clinical and roentgenographic findings in splenic methods are invasive and expensive. abscess. Arch Surg 3:1156-1159, 1976. Real-time ultrasonography has high sensitiv11. Brown J Summer T, Crowe J , Schaffner LD: Preoperative diagnosis of splenic abscess by ultraity for splenic pathology and it is repeatable in sonography and radionuclide scanning. South Med follow-up studies because of its noninvasiveJ 72:575-577, 1979. nessS4,l4Splenic abscesses appear as irregular, 12. Grant E, Martens MA, Mascatello VJ: Splenic abpoorly defined anechoic or hypoechoic masses.16 scess comparison of four imaging methods. A J R Gas may infrequently be detected within the ab132:465-466, 1979. scess as a hyperechoic area usually without 13. Coopersmith A, Ritchey AK, Zinkham WH: Fever ~hadowing.'~ Although this general appearance of unknown origin and value of Ga67,Tcg9" for decan be mimicked by lymphomatous masses, hefining abnormality of spleen. Johns Hopkins Med matomas, and fresh infarcts, it is very suggestive J 137:51-59, 1975. of an abscess in the proper clinical ~ e t t i n g . ' ~ , ~ ~ ,14. ' ~ Kurtz AB: The spleen, in Gastrointestinal SonogSonography definitely contributed to the early raphy, Kurtz AB, Goldberg BB (eds). Churchill Livingstone, New York, 1988, pp 139-164. diagnosis of the splenic abscess in our cases, and 15. Bydder GM, Kreel L: Computerized tomography we recommend that the spleen be scanned carein diagnosis of abdominal abscess. Comput Tofully in all patients with brucellosis.
REFERENCES 1. Madkour MM, A1 Karawi M: Gastrointestinal brucellosis, in Brucellosis, Madkour MM (ed). Butterworths, London, 1989, pp 140-151. 2. Spink WW: host parasite relationship in human brucellosis with prolonged illness due to suppuration of the liver and spleen. Am J Med Sci 35129, 1964.
VOL. 20, NO. 5,JUNE 1992
mogr 4:105-145, 1980. 16. Pawar S, Kay CJ, Gonzalez R, Taylor KJ, Rosenfield AT: Sonography of splenic abscess. A J R 138:259-262, 1982. 17. Sommer FG, Gonzalez R, Taylor KJ: Computed tomography and ultrasound findings of gascontaining splenic abscess. Yale J Biol Med 53:161, 1980. 18. Cunningham JJ: Ultrasonic finding in isolated lymphoma of the spleen stimulating splenic abscess. J Clin Ultrasound 6:412-414, 1978.
Case Report
Brucella melitensis Splenic Abscess: Sonographic Detection and Follow-Up Kemal Bahri Ate$, MD,* M. Enver Dolar, MD,* Mehmet Karahan, MD,? Gulay Temucin, MD,* and Leziz Onaran, MD*
Brucellosis is a disease affecting the reticuloendothelial system. Liver and spleen involvement has been reported to occur in 10% to 20% of the patients.' Splenic abscess is unusual, but it has been seen in brucellosis.2-6 We present 2 cases of splenic abscess related to Brucella melitensis, diagnosed from sonographic and bacteriological findings. CASE REPORTS Case 1
A 30-year-old woman was admitted to Yiiksek Ihtisas Hospital with complaints of fever, sweating, weakness, and weight loss for a period of one month. Vital signs showed a temperature of 38.6" C, pulse 104/min, and blood pressure 110/60 mm Hg. She appeared acutely ill. The liver was palpable 4 cm below the right costal margin. The spleen was palpable at 6 cm and was tender. Hemoglobin was 8 g/dL, white blood cell count 3400/mm3, erythrocyte sedimentation rate 68 mmh, serum glutamic- pyruvic transaminase 40 IU/L, and glutamic oxaloacetic transaminase 52 IU/L; other biochemical findings were normal. On ultrasonographic examination the liver was enlarged (vertical diameter: 15.0 cm) and its texture was normal. An anechoic lesion measuring 2.1 cm X 1.5 cm X 1.4 cm was seen near the right portal vein toward the porta hepatis. Splenic index was 32 em2. A hypoechoic intrasplenic mass with ill-defined walls, measuring 3.1 cm X 2.1 cm x 1.3 cm, was seen near the splenic hilum (Figure 1).In addition, there were
From the *Gastroenterology Department and tMicrobiology Department, Yiiksek Ihtisas Hospital, Ankara, Turkey. For reprints contact Kemal Bahri Ate$, MD, Gastroenterology Department, Yiiksek Ihtisas Hospital, Ankara, Turkey.
innumerable small (5 mm to 6 mm), oval-shaped, scattered anechoic lesions. The agglutinin titer for Brucella was 1/1280. B . melitensis grew in blood cultures. Echocardiography was normal. The patient was thought t o have hepatic and splenic abscesses related to B . melitensis. Tetracycline (2 g/day) and streptomycin (1g/day) therapy was started. Her symptoms disappeared in 6 days. Ultrasonographic followup revealed that the hepatic and splenic masses continued to become smaller. The therapy was continued for 4 weeks. All lesions disappeared 6 weeks later. She has remained in good health for 11 months. The liver and spleen returned to normal size. Case 2
A 50-year-old man was admitted to Yiisek Ihtisas Hospital with fever, sweating, and pain in the left upper quadrant for three weeks. Physical examination revealed a temperature of 38.7" C, pulse 96/min, and blood pressure 130180 mm Hg. The spleen was 4 cm below the left costal margin and tender. Laboratory findings were hemoglobin 10.3 g/dL, white cell count l1200/mm3 and erythrocyte sedimentation rate 65 mmh, serum glutamic- pyruvic transaminase 60 IU/L, and serum glutamic oxaloacetic transaminase 66 IU/L. The other biochemical results were within normal limits. Ultrasonographic examination revealed an enlarged spleen, multiple intrasplenic, small anechoic lesions and a 5.6 cm x 3.3 cm x 2.5 cm subcapsular anechoic lesion (Figure 2). Echocardiography was normal. The agglutinin titer for Brucella was 1/1280. Three blood cultures yielded B . melitensis. The patient was placed on tetracylin (2 g/day) and streptomycin (1g/day) therapy, and was discharged after satisfactory improvement. On ul349
350
CASE REPORT: ATEQ ET AL.
FIGURE 1. Oblique scan of the spleen showing a hypoechoic mass (arrowheads) near the hilum.
trasonographic examination all small lesions had disappeared, but the subcapsular lesion was still present 4 weeks later. Rifampicin (600 mgl day) was started and continued for 4 weeks. The subcapsular splenic collection disappeared by the end of this therapy. He has been symptom free for 10 months.
DISCUSSION
Brucellosis is a classical zoonotic disease. Brucella melitensis is the most common cause of human brucellosis. After the entry of brucella organisms into the human body, they pass through the lymphatics to the regional lymph nodes.
FIGURE 2. Longitudinal sonogram of the spleen showing subcapsular splenic abscess (arrowheads). JOURNAL OF CLINICAL ULTRASOUND
B R UCELLA MELITENSIS SPLENIC ABSCESS
351
3. Mc Garity WC, Sarafin D: Brucellosis: Indication They then invade the blood stream and localize for splenectomy. Am J Surg 115:355-363, 1968. in body organs that are rich in reticuloendothe4. Dubbins FA: Ultrasound in the diagnosis of lial tissue, such as lymph nodes, bone marrow, splenic abscess. Br J Radiol 53:489-491, 1980. liver, and spleen.' Caseation necrosis and ab5 . Nelken N, Ignatins J , Shinner M, Christensen N: scess formation occurs in infections caused by B. Changing clinical spectrum of splenic abscess. A m suis and is less frequently seen in infections due J Surg 154:27-33, 1987. to other Brucella species.'r7*'Brucella suis is the 6. Chulay JD, Lankeram MR: Splenic abscess: Remain species isolated from liver and spleen abport of 10 cases and review of the literature. Am J scesses.' A review of the literature failed to idenMed 61513-521, 1976. tify any prior report of B. melitensis-related 7. Mittelstaed CA, Partain CL: Ultrasonic pathologic spleen abscesses. Only 1 patient with a B . classification of splenic abnormalities: Gray scale patterns. Radiology 134:697-705, 1980. melitensis-related cerebellar abscess has been re8. Spink WW: Suppuration and calcification of the p~rted.~ liver and spleen due to long standing infection The conventional radiologic methods are nonwith Brucella suis. N Engl J Med 257:209-210, specific in the diagnosis of splenic 1957. The sensitivity and specificity of the splenic 9. Gaytan JA, Baqueiro HO, Maza MD: Brucella scanning with 9 9 m Tsulphur ~ colloid and gallium melitensis cerebellar abscess. J Infect Dis 67 citrate are 10w.ll-'~Scaning with indium-111 1601730-731, 1989. labeled leucocytes and computed tomography are 10. Miller FJ, Rothermel FJ, O'Neil MT, Schochat JJ: more valuable. l4,I5 However, all these diagnostic Clinical and roentgenographic findings in splenic methods are invasive and expensive. abscess. Arch Surg 3:1156-1159, 1976. Real-time ultrasonography has high sensitiv11. Brown J Summer T, Crowe J , Schaffner LD: Preoperative diagnosis of splenic abscess by ultraity for splenic pathology and it is repeatable in sonography and radionuclide scanning. South Med follow-up studies because of its noninvasiveJ 72:575-577, 1979. nessS4,l4Splenic abscesses appear as irregular, 12. Grant E, Martens MA, Mascatello VJ: Splenic abpoorly defined anechoic or hypoechoic masses.16 scess comparison of four imaging methods. A J R Gas may infrequently be detected within the ab132:465-466, 1979. scess as a hyperechoic area usually without 13. Coopersmith A, Ritchey AK, Zinkham WH: Fever ~hadowing.'~ Although this general appearance of unknown origin and value of Ga67,Tcg9" for decan be mimicked by lymphomatous masses, hefining abnormality of spleen. Johns Hopkins Med matomas, and fresh infarcts, it is very suggestive J 137:51-59, 1975. of an abscess in the proper clinical ~ e t t i n g . ' ~ , ~ ~ ,14. ' ~ Kurtz AB: The spleen, in Gastrointestinal SonogSonography definitely contributed to the early raphy, Kurtz AB, Goldberg BB (eds). Churchill Livingstone, New York, 1988, pp 139-164. diagnosis of the splenic abscess in our cases, and 15. Bydder GM, Kreel L: Computerized tomography we recommend that the spleen be scanned carein diagnosis of abdominal abscess. Comput Tofully in all patients with brucellosis.
REFERENCES 1. Madkour MM, A1 Karawi M: Gastrointestinal brucellosis, in Brucellosis, Madkour MM (ed). Butterworths, London, 1989, pp 140-151. 2. Spink WW: host parasite relationship in human brucellosis with prolonged illness due to suppuration of the liver and spleen. Am J Med Sci 35129, 1964.
VOL. 20, NO. 5,JUNE 1992
mogr 4:105-145, 1980. 16. Pawar S, Kay CJ, Gonzalez R, Taylor KJ, Rosenfield AT: Sonography of splenic abscess. A J R 138:259-262, 1982. 17. Sommer FG, Gonzalez R, Taylor KJ: Computed tomography and ultrasound findings of gascontaining splenic abscess. Yale J Biol Med 53:161, 1980. 18. Cunningham JJ: Ultrasonic finding in isolated lymphoma of the spleen stimulating splenic abscess. J Clin Ultrasound 6:412-414, 1978.
