Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Conservative Management of Splenic Abscesses in a Young, Immunocompetent Patient Madison D. Dudick, OMS-III, Dr. Marc Ciesco, DO. Edward Via College of Osteopathic Medicine, Spartanburg, SC.

Introduction

Figures

Discussion

References Splenic abscess is an important addition to the differential diagnosis of left upper quadrant pain secondary to its high mortality rate. This case report highlights management of an infection by Streptococcus constellatus . Fungal or parasitic sources warrant further investigation. In a young, immunocompetent patient, conservative management could be considered. An assessment of etiology, co-morbidities, and age are vital to this decision. finding, proposing this management as alternative to splenectomy. However, the initial development of the abscesses remains unclear. The patient had presented one month prior to a hospital in Charlotte, NC for a previous upper gastrointestinal bleed. These records were not available for review but could have contained pertinent information about etiology. Conclusion 1.Waheed, A., Mathew, G., & Zemaitis, M. R. (2019, July 4). Splenic Abscess. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519546/ 2.Weledji, E. P., & Zouna, F. (2022). A rare presentation of a splenic abscess. Clinical Case Reports, 10(2). https://doi.org/10.1002/ccr3.5493 3.Thipphavong, S., Duigenan, S., Schindera, S. T., Gee, M. S., & Philips, S. (2014). Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities. American Journal of Roentgenology, 203(2), 315 – 322. https://doi.org/10.2214/ajr.13.11777 4.Lucien, Nambiar, R., A Rauff, Mack, P., & Te Lu Yap. (1992). SPLENIC ABSCESS. Australian and New Zealand Journal of Surgery, 62(10), 780 – 784. https://doi.org/10.1111/j.1445 2197.1992.tb06917.x 5.Smyrniotis V, Kehagias D, Voros D, et al. Splenic abscess. Digestive surgery. 2000;17(4):354-357. doi:10.1159/000018878 6.Wu, H., & Zheng, R. (2020). Splenic abscess caused by Streptococcus anginosus bacteremia secondary to urinary tract infection: a case report and literature review. Open Medicine, 15(1), 997 – 1002. https://doi.org/10.1515/med-2020-0117 7.Lee, M.-C., & Lee, C.-M. (2018). Splenic Abscess: An Uncommon Entity with Potentially Life Threatening Evolution. The Canadian Journal of Infectious Diseases & Medical Microbiology = Journal Canadien Des Maladies Infectieuses et de La Microbiologie Médicale, 2018. https://doi.org/10.1155/2018/8610657 8.Lee, W.-S., Choi, S. T., & Kim, K. K. (2011). Splenic Abscess: A Single Institution Study and Review of the Literature. Yonsei Medical Journal, 52(2), 288. https://doi.org/10.3349/ymj.2011.52.2.288 The isolated bacteria and management of this patient’s splenic abscess differed from previously reported cases. Prior case reports document Streptococcus constellatus ’ involvement in the formation of empyemas.⁶ However, its role in splenic abscess, particularly in an immunocompetent patient with no clear etiology, has not been elucidated. Regardless of microbial etiology, the treatment of choice for a splenic abscess is splenectomy. Case reports focus on older patients with multiple co morbidities in which this management is warranted.⁷ ⁻ ⁸ Yet, this patient was young and immunocompetent, provoking a dialogue on the consequences of losing her spleen’s vital functions versus the benefit of conservative management. The abscesses resolved over three months from initial

A splenic abscess is a rare infection, particularly in a young, immunocompetent patient with an incidence of 0.2%.¹ The spleen has numerous functions, including providing immune response to blood-borne pathogens, filtering and storing blood, and producing white blood cells.² A differential for splenic abscesses includes pyogenic, fungal, or parasitic sources.³ Streptococcus constellatus , a digestive tract commensal, was isolated from the patient’s peritoneal fluid culture. Splenic abscess is a rare infection commonly caused by endocarditis, pneumonia, gastrointestinal (GI) perforation or arteriovenous malformation.⁴ The patient did not possess these risk factors, as GI perforation was ruled out by gastrografin study. Splenic abscesses are more common and lethal in immunosuppressed patients with a mortality rate of 80%.⁵ This patient was immunocompetent with a relevant mortality rate of 15%.¹ The treatment of choice is splenectomy.² Due to the patient’s age, the patient elected to manage conservatively with drains, antibiotics, and close follow-up with interventional radiology (IR). Context: A 26-year-old female presented to the emergency department with an upper gastrointestinal bleed and severe pain in the left upper quadrant. The patient had a significant past medical history of a bleeding duodenal ulcer that required multiple transfusions one month prior. The present bleed was secondary to a duodenal ulcer which was treated by embolization. Her pain worsened with inspiration, and imaging was warranted to rule out a pulmonary embolism. Computed tomography (CT) of the chest incidentally found multiple splenic abscesses with reflex CT imaging of the abdomen and pelvis showing several large abscesses in the central aspect of the spleen that invaded the posterior aspect of the stomach, the superior wall of the transverse colon, and the undersurface of the hemidiaphragm. Management: The patient was initiated on intravenous fluids and broad spectrum antibiotics, including piperacillin-tazobactam and fluconazole. Surgery was consulted. The patient elected to pursue conservative treatment, and a drain was placed by IR. Blood cultures remained negative. The patient’s peritoneal fluid culture returned as Streptococcus constellatus . Outcome: The patient was discharged on amoxicillin/clavulanic acid with outpatient follow-up with IR to monitor drain output and to obtain serial imaging to ensure resolution of the splenic abscesses. Follow-Up: IR repeated CT of abdomen and pelvis on 10/02/2023 and 10/26/2023. The anterior, inferior, and upper pole abscesses were resolving, and the drain continued to have sanguineous output daily. On 11/28/2023, the abscess cavities had resolved, and the drain was finally removed. Case Description

Figure 1 . CT of the abdomen and pelvis with contrast completed on September 1st, 2023. Demonstrates a large abscess in the central aspect of the spleen that is irregularly shaped. It is measured as 5 x 5 x 13 cm. It extends through the superior margin of the splenic capsule and abuts the undersurface of the hemidiaphragm. The second abscess involves the posterior aspect of the stomach and spleen, and it measures 14 x 10 x 10 cm.

Figure 2 . CT of the abdomen and pelvis with contrast completed on October 2nd, 2023. A. Inferior margin of the spleen, there is a 5.3 x 3.9 cm fluid collection. B. Anterior spleen, there is an 2.6 x 2.4 cm fluid collection. C. Upper pole of the spleen, there is a 4.1 x 2.0 cm fluid collection.

Figure 3 . CT abdomen pelvis with contrast completed on October 26th, 2023. A. Inferior margin of the spleen, there is a 2.7 x 2.2 cm fluid collection. B. Anterior spleen, there is an 12 x 13 mm fluid collection. In the upper pole of the spleen, the fluid collection has resolved.

Thank you to Dr. Marc Ciesco for his guidance and advice on this case report. Thank you also to the patient who decided to participate in this case report to increase awareness for the diagnosis and management of her condition.

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2024 Research Recognition Day