Splenic Abscess in a Tropical Zone Frank N. Ihekwaba, MB, CHB, FRCS Ibadan, Nigeria
Abscess of the spleen is uncommon. The reported incidence varies widely and early observations of an association with tropical fevers are no longer evident. The pathogenesis is ill-understood and diagnosis is difficult and usually late. A careful clinical examination combined with the recent utilization of 99Technitium scanning and splenic arteriography now permit early diagnosis. Splenectomy is the treatment of choice. While it is encountered worldwide, abscess of the spleen is an uncommon surgical condition. Although Hippocrates' recognized it, as did the physicians of ancient India, clinicians are still uncertain as to its pathogenesis. The reported incidence varies greatly, owing to a relative lack of awareness of the condition and to difficulties in diagnosis. Reid and Lang,2 in three large series totaling 16,524 cases, found only 66 cases, an incidence of 0.4 percent. Wallace3 in Northern Rhodesia (now Zambia), however, was able to collect 49 cases in two years. Previous observers3-5 had suggested that the entity was more to be found in the tropics than in Europe and America, attributing this impression to the environment of typhoid and paratyphoid fevers, malaria, the dysenteries, schistosomiasis, and relapsing fever. This view is now to be doubted.
Material In the 15-year period 1962-1977, 78 cases of disease involving the spleen
Requests for reprints should be addressed to Dr. Frank N. Ihekwaba, Department of Surgery,
University College Hospital, Ibadan, Nigeria.
only were recorded at the University College Hospital, Ibadan. In 15 cases (19.2 percent), the principal diagnosis was abscess of this organ. The manner of presentation, diagnostic procedures and the management of the condition form the basis of this study. It will be seen that this entity, far from being a tropical problem, is no different in its incidence and manifestations than those seen in other parts of the world. In addition, an explanation of the pathogenesis is offered and the pathology described.
Clinical Manifestations The ages of the 15 patients ranged from five to 60 years; the majority ranged from 21 to 40 years.
Sex The sex distribution was male/ female- 1.5/1.
Length of History Many patients were uncertain about the onset of their illness, a not altogether surprising situation in a largely uneducated population. Of the 11 patients from whom information was obtainable and judged reliable, one was
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
for 24 hours; four for seven days; three for 14 days; and three for up to two months.
Symptoms and Signs A major complaint was upper abdominal pain especially in the left upper quadrant. Thirteen of the 15 patients (86.6 percent) had this complaint. Only one patient located his pain in the retrosternal region; the other had pain in the left iliac fossa. The pain was dull and dragging in character. It was referred to the left shoulder tip in only two cases. It was exacerbated by deep breathing or coughing. A tender left hypochondrial mass, with firmness and guarding in this region, was present. This was found in all cases studied. A swinging fever, over 38C, was recorded in 10 of the patients. Dyspnea, with left-sided pleuritic pain (four patients), and a dull percussion note in the left lower chest (five patients), suggested left basal pneumonitis and/or effusion. Cough was an inconstant feature of the condition. Other features included malaise and loss of appetite extending over a period of up to 40 days before they sought medical attention.
Laboratory Studies Laboratory data suggested the presence of a chronic inflammatory focus. Eleven of the patients (73.3 percent) were anemic with hematocrit values in the range 18-32 percent. The blood picture showed anisocytosis and polychromasia. Leukocytosis was a constant finding, the range lying between 8,400 to 26,400. The differential count 259
ni
q t |
21-10
11-20
21-30 AGE
31-40
2
41-5
~~~~~~~FEMALE
'W
(YEARS)
Figure 1. Age and sex distribution.
was of normal pattern. Blood smear was negative for parasites. The blood group distribution was irregular, with 0 Rh + - 6; A Rh + - 2; B Rh + - 3; and AB Rh + - 1. There was no Rhesus negative in the group studied. The genotype was studied in 12 patients. There were AA - 5; AS - 5; SC - 2; and SS - 0. Liver function tests were within normal range, but the serum albumin levels were on the lower side of normal (1.9 - 3.3 g/100 ml: average -2.4 g/100 ml). Blood culture yielded no growth in ten of 11 patients sampled (91 percent). Splenic pus culture in three cases yielded Staphyloccocus aureus (one case) and Salmonella typhi (two cases), one of which coliforms were also isolated. Stool cultures were negative for schistosoma and dysentric organisms. Mid-stream urine specimens were reported as sterile. Radiological investigations, a major tool in the diagnostic process, included erect and supine views of the abdomen, chest films, and contrast studies, eg, barium meal and splenic arteriograms. Elevation of the left dome of the diaphragm was seen in five patients (33 percent) and displacement of the stomach and splenic flexure of the colon to the midline was noted in 14 cases (93.3 percent). Left basal consolidation was found in five cases (33.3 percent) as was a pleural effusion on the left side. Splenic arteriography was performed in only three cases. One case showed vascular obstruction at the splenic hilum; the other two cases were not diagnostic. Diagnosis depended on the history of pain and tenderness in the left hypochondrium, splenomegaly, fever, anemia, leukocytosis, and left basal chest signs. Confirmation is obtained by arteriography and splenic scanning.
Treatment Conservative treatment, utilizing the broad spectrum antibiotic, tet260
racycline, was chosen in six cases. In five of these cases, a previously large, tender spleen was observed to shrink and become nontender after approximately one month of therapy. The fever, anemia, and leukocytosis all gradually improved. One patient died. She was quite ill on admission and failed to respond to medical treatment. Autopsy revealed generalized peritonitis and liver and splenic abscesses. Exploratory laparotomy was performed in seven cases (46.6 percent). Perisplenitis, with dense adhesions to adjacent structures, was a constant finding in these cases. The spleen was large and had a thickened capsule. In six cases, the capsule had ruptured, releasing a large volume (in one case three litres) of anchovy-sauce pus which filled the left subphrenic and subsplenic spaces. Splenectomy was performed in all cases. Drainage only had been carried out in two cases where a huge abscess collection had been encountered at laparotomy in the referring hospitals. These later had splenectomy performed.
Pathology The thick walled capsule enclosed a hemorrhagic, splenic pulp with areas of necrosis. In the case of the solitary abscess, the cavity was large and compressed much of the surrounding splenic pulp. In the multiple abscess type, the abscesses were small and surrounded by apparently normal splenic tissue. The branches of the splenic artery, in some cases, had become obstructed with areas of infarction distally. Microscopically, the sections showed congestion and multiple recent hemorrhagic infarcts.
Discussion Splenic abscess, although uncommon, has been the subject of inquiry by a number of workers during the last 100 years. Classification varied and the early literature 67 recognized single and multiple abscesses. Single abscesses were usually large and susceptible to easy rupture. Multiple abscesses were generally small and were mostly discovered in the autopsy room. Later, study of the entity rested on the type of microbiological isolate, a rather unrewarding method since very few organisms were recovered from cultural studies. Recently, however, classifica-
tion based upon the predisposing factors became widely applied so that primary and secondary abscesses were recognized. Thus primary splenic disease,3'5 trauma,4'8'9 depressed immune reactions, and red cell surface abnormalities'0 became important aetiological considerations. Kuttner7 recognized three types: (1) Post-traumatic (15 percent); (2) Spread from neighboring pathological processes, eg, leaking gastric ulcer or carcinoma, colonic neoplasms (10 percent); and (3) Metastatic spread of infection elsewhere, eg, portal vein, splenic artery (75 percent). The concept of primary splenic abscess as an entity is denied" but as this study shows it is real. Although analysis based on these lines helps in the understanding of the etiological process, it adds little to the management of the patient presenting with acute splenic abscess requiring urgent treatment. An important consideration, however, is the mode of formation of the splenic abscess. Various theories have been advanced to explain the pathogenesis of this entity. Arterial dissemination of an infected embolus from a distant focus, septicemia or pyemia, may give rise to septic infarction of branches of the splenic artery. The resulting suppuration and tissue breakdown ("sequestrating abscess of Kuttner") in typical cases, is a shredded mass of necrotic splenic pulp. All manner of primary foci have been reported: otitis media, carbuncle'2 mastoid with extradural abscess," bacterial endocarditis,"4 abdominal sepsis, and intravenous abuse of heroin.'5 Thrombosis of splenic vein,'5"6 was also suggested as an important predisposing factor. No age group is exempt from this condition, the child being as susceptible to splenic infarction and abscess formation as the adult. The male/female ratio showed a preponderance of the former by a factor of 50 percent. The length of history was variably long as is to be expected in a population that seeks medical treatment only when they could no longer bear the prostration occasioned by the illness. The symptoms and signs of splenic abscess are generally variable, and may be acute or chronic. The acute case, less than seven days, may be sudden in onset and without any recognizable predisposing factors. The large splenic abscess with nup-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
ture presents the picture of peritonitis. Chronic abscess of the spleen is usually of insidious onset. It may be small, and located in the upper pole where it is protected from clinical attention. Multiple small abscesses may never be detected during life. Left upper quadrant pain and tenderness is elicitable in a majority of the patients. Indeed this was the major complaint that brought the patients to hospital. The pain was dull and dragging, becoming sharp on deep breathing. Kehr's sign was positive in two cases only. Generally thought to be an infrequent complaint, Lowenfels,17 nevertheless, stressed its importance, if present, as an aid in diagnosis. A left hypochondrial mass is usually present in the majority of cases. This mass is either the enlarged spleen or the result of inflammatory adhesions involving the omentum, spleen, stomach, and colon. Tenderness and guarding over this mass may make deeper palpation difficult. In large abscesses, the organ may become fluctuant;5 if the splenic pus has undergone colliquative change, a fluid thrill may be elicited. Fever is present and may be continuous or remittent, in most cases over 38C. A few cases may present with normal or nearly normal temperature, in these cases the result of uncontrolled antibiotic self-medication. Malaise and loss of appetite is frequent. A left pleural effusion with signs of basal consolidation is of added significance and would suggest subdiaphragmatic inflammation. Laboratory data were only of modest assistance in diagnosis in the cases studied. Anemia was a constant finding at one stage or other in the disease process. In the three cases in which the hematocrit was in the normal range, evidence was available to suggest self-medication with hematinics when the patients began to lose energy and appetite. The leukocyte elevations ranged from upper normal to 26,400. Several authors;l18 regard the elevations of the white cell count as inconstant and variable. The blood group distribution had no definable pattern. All the patients were Rhesus positive. The genotypic distribution as demonstrated by hemoglobin electrophoresis showed seven patients (58.3 percent) to carry the S gene for sickle cell disease. Watson-Williams'9 and Esan20 in Ibadan thought that only about 24 percent of the population car-
Table 1. Summary of Symptoms and Signs and Their Diagnostic Value
Symptoms and Signs
Number of Cases
Percentage
Diagnostic Value
13
86.6
Good
15
100.0
Good
10 5
66.6 33.3
Good Good
11 Variable 15
73.3
Abdominal pain and tenderness Left hypochondrial mass Fever 38C Pleural effusion and consolidation Laboratory Data Anemia Leukocytosis Blood type (Rh+) Genotype AS + SC SS Blood culture (positive) Pus culture Arteriography (positive) Scan X-ravs: Elevated immobile left diaphragm Splenic gas
7
100.0 58.3
1 6 5
9 37.5 33.3
5
33.3
Good
Good Good Good Good
Table 2. Treatment Modality and Mortality Treatment Medical
Splenotomy and drainage Splenectomy
Number 6 2 7
(+2)
Clinical Condition*
Fair-average Very poor Average to poor
Mortality 16.6 0 0
*Fair.
Moderate splenomegaly, pain, tenderness, fever, tachycardia and leukocytosis. Average- Splenomegaly and or splenic rupture Very poor- Very ill, toxic, massive splenomegaly, splenic rupture, and huge subdiaphragmatic collection.
ried the S gene. Beet"' had suggested an etiological relationship between the presence of Hb S and splenic abscess. Cockshott and Weaver" after studying six cases showed that the S gene was probably a predisposing factor for abscess of the spleen. The exact role of the S gene is unexplained, but this larger study would seem to confirm the suggestion of a relationship between the S gene and abscess of the spleen. Liver function was not significantly deranged. Blood culture was unhelpful and a majority of workers6" 5 report sterile cultures. Only in one case was a positive culture obtained. Culture of the pus, encountered at operation in three cases, only yielded Staphyloccocus aureus (1 case), Salmonella typhi
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
(2 cases), and coliforms in one of the latter. Sterile splenic pus was a constant finding by many workers.:35'5"5 The septicemia of typhoid fever is thought to be a major source of splenic abscess. Wellman,2' Morel et al,22 Pickleman et al,"' and Gadacz et al'5 report several cases. Kuttner7 incriminated this organism in 14 percent of his cases. Yet in Ibadan where salmonellosis is an important disease entity, it is surprising that this organism fails to confirm itself in this role. Except in the one case where Salmonella typhi had been isolated from blood culture, the primary source of the organism was never discovered in the cases here studied. Neither malaria, schistosoma, dysentry, nor relapsing 261
tion, it is quite safe. This technique, in the diagnosis of space-occupying lesions, holds considerable promise for the future. Unfortunately, this isotope is not yet available to us at the University College Hospital, Ibadan.
Figure 2. Photograph of abscessed spleen measuring .23 x 14 x 8 cm with its capsule partially separated from the soft, friable ragged pulp. The cavities within the organ were ragged, hemorrhagic, and contained anchovy sauce material.
fever was found in association with abscess of the spleen. The claim by earlier investigators in this fi'eld, implying this association is thus not proved by this study. It would seem rather that because of the unique position of the spleen as a filtering organ for organisms, any pathology which diminished this function would render it open to invasion and abscess formation. speiU bcs.Wthahl-ieo i Valuable information was obtained hurandeaigtyila14KV from of the examinations gamU radiological htnol,btn earda chest and abdomen. Elevation of an immobile left hemidiaphragm, with displacement of the stomach and splenic flexure of the colon to the midline, suggested an inflammatory subdiaphragmatic lesion. A left pleural effusion, and rarely, gas in the spleen manifested either as an air-fluid level or as gas bubbles were virtually diagnostic. 16.2:3.24 Selective splenic arteriography, utilized in three cases, was unhelpful in one case owing to technical diff'iculties, but in the other two cases, suggested obstruction at the hilum in the one, and in the other, splenic opacifi'cation with areas of translucency. This procedure is an important tool in the investigation of splenic disease.
An important development in the investigation and diagnosis of splenic abscess is the scintiscanning process using 99mTe-Technitium sulphur colloid, a radionuclide of molybdenum 99 which is injected intravenously. Sev-
eral workers 11125 report the successful technique in the diagnosis of
use of this
262
Course Untreated, the majority go on to a fatal termination with dissemination of abscesses to the liver, brain, kidneys etc. A minority may progress to chronic discharging sinuses which open either into a hollow viscus, eg, stomach or colon, or through the diaphragm with empyema formation, or through the skin. Treatment offers the chance of cure. As shown in this study, successful treatment has varied from the purely medical to surgical. Early workers advised antibiotic therapy, either because the diagnosis was in doubt or the patient judged not too ill. Six cases were so treated, using the available broad spectrum antibiotic, tetracycline. In five cases the previously large, tender spleen shrank so much as to become impalpable after one month of therapy. Hewitt26 believed that 50 to 60 percent of cases were cured by medical treatment alone. Morel et al,22 *however, recorded 43 fatalities in 57 patients (75.4 percent) in those not treated surgically, while McSherry and Dineen27 reported 100 percent mortality. Medical treatment, although successful in many cases, still left the patient at risk, since a residual focus of infection could persist. This focus could reactivate and seed bacteria to other organs. Splenotomy and drainage of the abscess was the treatment elected by other clinicians, especially when the patient was too ill and the abscess massive. Improvement was followed by splenectomy later. Two patients were so treated. In Billing's8 collected series, 51 of 55 cases were treated by splenotomy and drainage. He recorded seven fatalities (13 percent). Splenectomy, a hazardous and laborious procedure, was successfully carried out in nine patients. If the enlarged organ is densely adherent to the diaphragm and surrounding structures, splenectomy offers cure. Hemorrhage can be profuse, but if the splenic artery is first ligated in the lesser sac, the abscessed organ may then be removed in toto or piecemeal. The splenic bed is
drained using a large bore tube drain. Antibiotic therapy is continued postoperatively until the clinical signs of persisting infection are abolished. Prognosis depends on whether the abscess involves the spleen only, or whether other organs are similarly involved. Splenectomy offers cure in solitary cases. When the abscessed organ has ruptured, and generalized peritonitis with multiple organ involvement has occurred, the outlook is grave.
Literature Cited 1. Hippocrates: Cited by Grand-Moursel. Contribution a 1'etude abces de la rate. These de Paris, 1885 2. Reid SE, Lang SY: Abscess of the spleen. Am J Surg 88:912-916, 1954 3. Wallace A: Abscess of spleen in the tropics. Med J South Africa 17:155-159, 1922 4. Elting AW: Abscess of the spleen. Ann Surg 62:182-186, 1915 5. Jelliffe DB: Splenic abscess in the tropics. J Trop Med 52:134-140, 1949 6. Grand-Moursel: Contribution a 1'etude abces de la rate. These de Paris, 1885 7. Kuttner H (1907) in Wolfson IN: Abscess of Spleen. N Engl J Med 230:135-137, 1944 8. Billings AE: Abscess of the spleen. Ann Surg 88:416-419, 1928 9. Inlow WD: Traumatic abscess of the spleen. Ann Surg 85:368-370, 1927 10. Beet EA: Primary splenic abscess and sickle cell disease. East Afr Med J 26:180-186, 1949 11. Cockshot WP, Weaver EJM: Primary tropical splenic abscess: A misnomer. Brit J Surg 49:665-669, 1962 12. Cutler EC: Splenic abscess. JAMA 75:1712-1715, 1920 13. Walker IJ: Abscess of the spleen. N EngI J Med 203:1025-1028, 1930 14. Friedberg CK: Diseases of the Heart, ed 3. Philadelphia, WB Saunders, 1966, p 1385 15. Gadacz T, Way LW, Dunphy JE: Changing clinical spectrum of splenic abscess. Am J Surg 128:(2). 182-187, 1974 16. Gelfand M: Primary splenic abscess. Trans R Soc Trop Med Hyg 140:789-793, 1947 17. Lowenfels AB: Kehr's sign: A neglected aid in rupture of the spleen. N Engl J Med 274:1019, 1966 18. Pickleman JR: Paloyan E, Block GE: The surgical significance of splenic abscess. Surgery 68:287-293, 1970 19. Watson-Williams J: Annual Report of Pathology Department. University College Hospital, Ibadan, 1959 20. Esan GJF: Thalassaemia syndromes in Nigeria. Br J Haemat 19:47-56, 1970 21. Wellman FC: Splenic abscess. J Trop Med Hyg 7:125-129, 1904 22. Morel C, Dambrin C, Tapie J: Abscess of spleen in typhoid. Ann Med 19:5-18, 1926 23. Frankel A, Ashikari H, Dreiling DA, et al: Splenic abscess. J Mount Sinai Hosp NY 33:404-407, 1966 24. Gelfand M: Splenic abscess. Lancet (2) 904-905, 1947b 25. Zook EG: The value of scintiscans in the diagnosis of splenic abscess. Surg Gynecol Obstet 131:1125-1129, 1970 26. Hewitt WL: Penicillin in the Treatment
of Pulmonary Infections. Med Clin North Am 32:1207-1225, 1948 27. McSherry CK, Dineen P: The significance of splenic abscess. Am J Surg 103:618624, 1962
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
Abscess of the spleen is uncommon. The reported incidence varies widely and early observations of an association with tropical fevers are no longer evident. The pathogenesis is ill-understood and diagnosis is difficult and usually late. A careful clinical examination combined with the recent utilization of 99Technitium scanning and splenic arteriography now permit early diagnosis. Splenectomy is the treatment of choice. While it is encountered worldwide, abscess of the spleen is an uncommon surgical condition. Although Hippocrates' recognized it, as did the physicians of ancient India, clinicians are still uncertain as to its pathogenesis. The reported incidence varies greatly, owing to a relative lack of awareness of the condition and to difficulties in diagnosis. Reid and Lang,2 in three large series totaling 16,524 cases, found only 66 cases, an incidence of 0.4 percent. Wallace3 in Northern Rhodesia (now Zambia), however, was able to collect 49 cases in two years. Previous observers3-5 had suggested that the entity was more to be found in the tropics than in Europe and America, attributing this impression to the environment of typhoid and paratyphoid fevers, malaria, the dysenteries, schistosomiasis, and relapsing fever. This view is now to be doubted.
Material In the 15-year period 1962-1977, 78 cases of disease involving the spleen
Requests for reprints should be addressed to Dr. Frank N. Ihekwaba, Department of Surgery,
University College Hospital, Ibadan, Nigeria.
only were recorded at the University College Hospital, Ibadan. In 15 cases (19.2 percent), the principal diagnosis was abscess of this organ. The manner of presentation, diagnostic procedures and the management of the condition form the basis of this study. It will be seen that this entity, far from being a tropical problem, is no different in its incidence and manifestations than those seen in other parts of the world. In addition, an explanation of the pathogenesis is offered and the pathology described.
Clinical Manifestations The ages of the 15 patients ranged from five to 60 years; the majority ranged from 21 to 40 years.
Sex The sex distribution was male/ female- 1.5/1.
Length of History Many patients were uncertain about the onset of their illness, a not altogether surprising situation in a largely uneducated population. Of the 11 patients from whom information was obtainable and judged reliable, one was
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
for 24 hours; four for seven days; three for 14 days; and three for up to two months.
Symptoms and Signs A major complaint was upper abdominal pain especially in the left upper quadrant. Thirteen of the 15 patients (86.6 percent) had this complaint. Only one patient located his pain in the retrosternal region; the other had pain in the left iliac fossa. The pain was dull and dragging in character. It was referred to the left shoulder tip in only two cases. It was exacerbated by deep breathing or coughing. A tender left hypochondrial mass, with firmness and guarding in this region, was present. This was found in all cases studied. A swinging fever, over 38C, was recorded in 10 of the patients. Dyspnea, with left-sided pleuritic pain (four patients), and a dull percussion note in the left lower chest (five patients), suggested left basal pneumonitis and/or effusion. Cough was an inconstant feature of the condition. Other features included malaise and loss of appetite extending over a period of up to 40 days before they sought medical attention.
Laboratory Studies Laboratory data suggested the presence of a chronic inflammatory focus. Eleven of the patients (73.3 percent) were anemic with hematocrit values in the range 18-32 percent. The blood picture showed anisocytosis and polychromasia. Leukocytosis was a constant finding, the range lying between 8,400 to 26,400. The differential count 259
ni
q t |
21-10
11-20
21-30 AGE
31-40
2
41-5
~~~~~~~FEMALE
'W
(YEARS)
Figure 1. Age and sex distribution.
was of normal pattern. Blood smear was negative for parasites. The blood group distribution was irregular, with 0 Rh + - 6; A Rh + - 2; B Rh + - 3; and AB Rh + - 1. There was no Rhesus negative in the group studied. The genotype was studied in 12 patients. There were AA - 5; AS - 5; SC - 2; and SS - 0. Liver function tests were within normal range, but the serum albumin levels were on the lower side of normal (1.9 - 3.3 g/100 ml: average -2.4 g/100 ml). Blood culture yielded no growth in ten of 11 patients sampled (91 percent). Splenic pus culture in three cases yielded Staphyloccocus aureus (one case) and Salmonella typhi (two cases), one of which coliforms were also isolated. Stool cultures were negative for schistosoma and dysentric organisms. Mid-stream urine specimens were reported as sterile. Radiological investigations, a major tool in the diagnostic process, included erect and supine views of the abdomen, chest films, and contrast studies, eg, barium meal and splenic arteriograms. Elevation of the left dome of the diaphragm was seen in five patients (33 percent) and displacement of the stomach and splenic flexure of the colon to the midline was noted in 14 cases (93.3 percent). Left basal consolidation was found in five cases (33.3 percent) as was a pleural effusion on the left side. Splenic arteriography was performed in only three cases. One case showed vascular obstruction at the splenic hilum; the other two cases were not diagnostic. Diagnosis depended on the history of pain and tenderness in the left hypochondrium, splenomegaly, fever, anemia, leukocytosis, and left basal chest signs. Confirmation is obtained by arteriography and splenic scanning.
Treatment Conservative treatment, utilizing the broad spectrum antibiotic, tet260
racycline, was chosen in six cases. In five of these cases, a previously large, tender spleen was observed to shrink and become nontender after approximately one month of therapy. The fever, anemia, and leukocytosis all gradually improved. One patient died. She was quite ill on admission and failed to respond to medical treatment. Autopsy revealed generalized peritonitis and liver and splenic abscesses. Exploratory laparotomy was performed in seven cases (46.6 percent). Perisplenitis, with dense adhesions to adjacent structures, was a constant finding in these cases. The spleen was large and had a thickened capsule. In six cases, the capsule had ruptured, releasing a large volume (in one case three litres) of anchovy-sauce pus which filled the left subphrenic and subsplenic spaces. Splenectomy was performed in all cases. Drainage only had been carried out in two cases where a huge abscess collection had been encountered at laparotomy in the referring hospitals. These later had splenectomy performed.
Pathology The thick walled capsule enclosed a hemorrhagic, splenic pulp with areas of necrosis. In the case of the solitary abscess, the cavity was large and compressed much of the surrounding splenic pulp. In the multiple abscess type, the abscesses were small and surrounded by apparently normal splenic tissue. The branches of the splenic artery, in some cases, had become obstructed with areas of infarction distally. Microscopically, the sections showed congestion and multiple recent hemorrhagic infarcts.
Discussion Splenic abscess, although uncommon, has been the subject of inquiry by a number of workers during the last 100 years. Classification varied and the early literature 67 recognized single and multiple abscesses. Single abscesses were usually large and susceptible to easy rupture. Multiple abscesses were generally small and were mostly discovered in the autopsy room. Later, study of the entity rested on the type of microbiological isolate, a rather unrewarding method since very few organisms were recovered from cultural studies. Recently, however, classifica-
tion based upon the predisposing factors became widely applied so that primary and secondary abscesses were recognized. Thus primary splenic disease,3'5 trauma,4'8'9 depressed immune reactions, and red cell surface abnormalities'0 became important aetiological considerations. Kuttner7 recognized three types: (1) Post-traumatic (15 percent); (2) Spread from neighboring pathological processes, eg, leaking gastric ulcer or carcinoma, colonic neoplasms (10 percent); and (3) Metastatic spread of infection elsewhere, eg, portal vein, splenic artery (75 percent). The concept of primary splenic abscess as an entity is denied" but as this study shows it is real. Although analysis based on these lines helps in the understanding of the etiological process, it adds little to the management of the patient presenting with acute splenic abscess requiring urgent treatment. An important consideration, however, is the mode of formation of the splenic abscess. Various theories have been advanced to explain the pathogenesis of this entity. Arterial dissemination of an infected embolus from a distant focus, septicemia or pyemia, may give rise to septic infarction of branches of the splenic artery. The resulting suppuration and tissue breakdown ("sequestrating abscess of Kuttner") in typical cases, is a shredded mass of necrotic splenic pulp. All manner of primary foci have been reported: otitis media, carbuncle'2 mastoid with extradural abscess," bacterial endocarditis,"4 abdominal sepsis, and intravenous abuse of heroin.'5 Thrombosis of splenic vein,'5"6 was also suggested as an important predisposing factor. No age group is exempt from this condition, the child being as susceptible to splenic infarction and abscess formation as the adult. The male/female ratio showed a preponderance of the former by a factor of 50 percent. The length of history was variably long as is to be expected in a population that seeks medical treatment only when they could no longer bear the prostration occasioned by the illness. The symptoms and signs of splenic abscess are generally variable, and may be acute or chronic. The acute case, less than seven days, may be sudden in onset and without any recognizable predisposing factors. The large splenic abscess with nup-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
ture presents the picture of peritonitis. Chronic abscess of the spleen is usually of insidious onset. It may be small, and located in the upper pole where it is protected from clinical attention. Multiple small abscesses may never be detected during life. Left upper quadrant pain and tenderness is elicitable in a majority of the patients. Indeed this was the major complaint that brought the patients to hospital. The pain was dull and dragging, becoming sharp on deep breathing. Kehr's sign was positive in two cases only. Generally thought to be an infrequent complaint, Lowenfels,17 nevertheless, stressed its importance, if present, as an aid in diagnosis. A left hypochondrial mass is usually present in the majority of cases. This mass is either the enlarged spleen or the result of inflammatory adhesions involving the omentum, spleen, stomach, and colon. Tenderness and guarding over this mass may make deeper palpation difficult. In large abscesses, the organ may become fluctuant;5 if the splenic pus has undergone colliquative change, a fluid thrill may be elicited. Fever is present and may be continuous or remittent, in most cases over 38C. A few cases may present with normal or nearly normal temperature, in these cases the result of uncontrolled antibiotic self-medication. Malaise and loss of appetite is frequent. A left pleural effusion with signs of basal consolidation is of added significance and would suggest subdiaphragmatic inflammation. Laboratory data were only of modest assistance in diagnosis in the cases studied. Anemia was a constant finding at one stage or other in the disease process. In the three cases in which the hematocrit was in the normal range, evidence was available to suggest self-medication with hematinics when the patients began to lose energy and appetite. The leukocyte elevations ranged from upper normal to 26,400. Several authors;l18 regard the elevations of the white cell count as inconstant and variable. The blood group distribution had no definable pattern. All the patients were Rhesus positive. The genotypic distribution as demonstrated by hemoglobin electrophoresis showed seven patients (58.3 percent) to carry the S gene for sickle cell disease. Watson-Williams'9 and Esan20 in Ibadan thought that only about 24 percent of the population car-
Table 1. Summary of Symptoms and Signs and Their Diagnostic Value
Symptoms and Signs
Number of Cases
Percentage
Diagnostic Value
13
86.6
Good
15
100.0
Good
10 5
66.6 33.3
Good Good
11 Variable 15
73.3
Abdominal pain and tenderness Left hypochondrial mass Fever 38C Pleural effusion and consolidation Laboratory Data Anemia Leukocytosis Blood type (Rh+) Genotype AS + SC SS Blood culture (positive) Pus culture Arteriography (positive) Scan X-ravs: Elevated immobile left diaphragm Splenic gas
7
100.0 58.3
1 6 5
9 37.5 33.3
5
33.3
Good
Good Good Good Good
Table 2. Treatment Modality and Mortality Treatment Medical
Splenotomy and drainage Splenectomy
Number 6 2 7
(+2)
Clinical Condition*
Fair-average Very poor Average to poor
Mortality 16.6 0 0
*Fair.
Moderate splenomegaly, pain, tenderness, fever, tachycardia and leukocytosis. Average- Splenomegaly and or splenic rupture Very poor- Very ill, toxic, massive splenomegaly, splenic rupture, and huge subdiaphragmatic collection.
ried the S gene. Beet"' had suggested an etiological relationship between the presence of Hb S and splenic abscess. Cockshott and Weaver" after studying six cases showed that the S gene was probably a predisposing factor for abscess of the spleen. The exact role of the S gene is unexplained, but this larger study would seem to confirm the suggestion of a relationship between the S gene and abscess of the spleen. Liver function was not significantly deranged. Blood culture was unhelpful and a majority of workers6" 5 report sterile cultures. Only in one case was a positive culture obtained. Culture of the pus, encountered at operation in three cases, only yielded Staphyloccocus aureus (1 case), Salmonella typhi
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
(2 cases), and coliforms in one of the latter. Sterile splenic pus was a constant finding by many workers.:35'5"5 The septicemia of typhoid fever is thought to be a major source of splenic abscess. Wellman,2' Morel et al,22 Pickleman et al,"' and Gadacz et al'5 report several cases. Kuttner7 incriminated this organism in 14 percent of his cases. Yet in Ibadan where salmonellosis is an important disease entity, it is surprising that this organism fails to confirm itself in this role. Except in the one case where Salmonella typhi had been isolated from blood culture, the primary source of the organism was never discovered in the cases here studied. Neither malaria, schistosoma, dysentry, nor relapsing 261
tion, it is quite safe. This technique, in the diagnosis of space-occupying lesions, holds considerable promise for the future. Unfortunately, this isotope is not yet available to us at the University College Hospital, Ibadan.
Figure 2. Photograph of abscessed spleen measuring .23 x 14 x 8 cm with its capsule partially separated from the soft, friable ragged pulp. The cavities within the organ were ragged, hemorrhagic, and contained anchovy sauce material.
fever was found in association with abscess of the spleen. The claim by earlier investigators in this fi'eld, implying this association is thus not proved by this study. It would seem rather that because of the unique position of the spleen as a filtering organ for organisms, any pathology which diminished this function would render it open to invasion and abscess formation. speiU bcs.Wthahl-ieo i Valuable information was obtained hurandeaigtyila14KV from of the examinations gamU radiological htnol,btn earda chest and abdomen. Elevation of an immobile left hemidiaphragm, with displacement of the stomach and splenic flexure of the colon to the midline, suggested an inflammatory subdiaphragmatic lesion. A left pleural effusion, and rarely, gas in the spleen manifested either as an air-fluid level or as gas bubbles were virtually diagnostic. 16.2:3.24 Selective splenic arteriography, utilized in three cases, was unhelpful in one case owing to technical diff'iculties, but in the other two cases, suggested obstruction at the hilum in the one, and in the other, splenic opacifi'cation with areas of translucency. This procedure is an important tool in the investigation of splenic disease.
An important development in the investigation and diagnosis of splenic abscess is the scintiscanning process using 99mTe-Technitium sulphur colloid, a radionuclide of molybdenum 99 which is injected intravenously. Sev-
eral workers 11125 report the successful technique in the diagnosis of
use of this
262
Course Untreated, the majority go on to a fatal termination with dissemination of abscesses to the liver, brain, kidneys etc. A minority may progress to chronic discharging sinuses which open either into a hollow viscus, eg, stomach or colon, or through the diaphragm with empyema formation, or through the skin. Treatment offers the chance of cure. As shown in this study, successful treatment has varied from the purely medical to surgical. Early workers advised antibiotic therapy, either because the diagnosis was in doubt or the patient judged not too ill. Six cases were so treated, using the available broad spectrum antibiotic, tetracycline. In five cases the previously large, tender spleen shrank so much as to become impalpable after one month of therapy. Hewitt26 believed that 50 to 60 percent of cases were cured by medical treatment alone. Morel et al,22 *however, recorded 43 fatalities in 57 patients (75.4 percent) in those not treated surgically, while McSherry and Dineen27 reported 100 percent mortality. Medical treatment, although successful in many cases, still left the patient at risk, since a residual focus of infection could persist. This focus could reactivate and seed bacteria to other organs. Splenotomy and drainage of the abscess was the treatment elected by other clinicians, especially when the patient was too ill and the abscess massive. Improvement was followed by splenectomy later. Two patients were so treated. In Billing's8 collected series, 51 of 55 cases were treated by splenotomy and drainage. He recorded seven fatalities (13 percent). Splenectomy, a hazardous and laborious procedure, was successfully carried out in nine patients. If the enlarged organ is densely adherent to the diaphragm and surrounding structures, splenectomy offers cure. Hemorrhage can be profuse, but if the splenic artery is first ligated in the lesser sac, the abscessed organ may then be removed in toto or piecemeal. The splenic bed is
drained using a large bore tube drain. Antibiotic therapy is continued postoperatively until the clinical signs of persisting infection are abolished. Prognosis depends on whether the abscess involves the spleen only, or whether other organs are similarly involved. Splenectomy offers cure in solitary cases. When the abscessed organ has ruptured, and generalized peritonitis with multiple organ involvement has occurred, the outlook is grave.
Literature Cited 1. Hippocrates: Cited by Grand-Moursel. Contribution a 1'etude abces de la rate. These de Paris, 1885 2. Reid SE, Lang SY: Abscess of the spleen. Am J Surg 88:912-916, 1954 3. Wallace A: Abscess of spleen in the tropics. Med J South Africa 17:155-159, 1922 4. Elting AW: Abscess of the spleen. Ann Surg 62:182-186, 1915 5. Jelliffe DB: Splenic abscess in the tropics. J Trop Med 52:134-140, 1949 6. Grand-Moursel: Contribution a 1'etude abces de la rate. These de Paris, 1885 7. Kuttner H (1907) in Wolfson IN: Abscess of Spleen. N Engl J Med 230:135-137, 1944 8. Billings AE: Abscess of the spleen. Ann Surg 88:416-419, 1928 9. Inlow WD: Traumatic abscess of the spleen. Ann Surg 85:368-370, 1927 10. Beet EA: Primary splenic abscess and sickle cell disease. East Afr Med J 26:180-186, 1949 11. Cockshot WP, Weaver EJM: Primary tropical splenic abscess: A misnomer. Brit J Surg 49:665-669, 1962 12. Cutler EC: Splenic abscess. JAMA 75:1712-1715, 1920 13. Walker IJ: Abscess of the spleen. N EngI J Med 203:1025-1028, 1930 14. Friedberg CK: Diseases of the Heart, ed 3. Philadelphia, WB Saunders, 1966, p 1385 15. Gadacz T, Way LW, Dunphy JE: Changing clinical spectrum of splenic abscess. Am J Surg 128:(2). 182-187, 1974 16. Gelfand M: Primary splenic abscess. Trans R Soc Trop Med Hyg 140:789-793, 1947 17. Lowenfels AB: Kehr's sign: A neglected aid in rupture of the spleen. N Engl J Med 274:1019, 1966 18. Pickleman JR: Paloyan E, Block GE: The surgical significance of splenic abscess. Surgery 68:287-293, 1970 19. Watson-Williams J: Annual Report of Pathology Department. University College Hospital, Ibadan, 1959 20. Esan GJF: Thalassaemia syndromes in Nigeria. Br J Haemat 19:47-56, 1970 21. Wellman FC: Splenic abscess. J Trop Med Hyg 7:125-129, 1904 22. Morel C, Dambrin C, Tapie J: Abscess of spleen in typhoid. Ann Med 19:5-18, 1926 23. Frankel A, Ashikari H, Dreiling DA, et al: Splenic abscess. J Mount Sinai Hosp NY 33:404-407, 1966 24. Gelfand M: Splenic abscess. Lancet (2) 904-905, 1947b 25. Zook EG: The value of scintiscans in the diagnosis of splenic abscess. Surg Gynecol Obstet 131:1125-1129, 1970 26. Hewitt WL: Penicillin in the Treatment
of Pulmonary Infections. Med Clin North Am 32:1207-1225, 1948 27. McSherry CK, Dineen P: The significance of splenic abscess. Am J Surg 103:618624, 1962
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