Virginia Research Day 2021

Medical Resident Research Case Reports

16 Splenic Abscess and Multilobe Pneumonia in a Patient with G6PD Deficiency

Chelsea M. Dalfrey, DO; Ryan O’Connell, DO Corresponding author: michael.moore1@LPNT.net

SOVAH Health Internal Medicine Residency Program

Context: Splenic abscess is rare, occurring in immunocompromised patients from hematogenous spread. Glucose-6-phospate dehydrogenase (G6PD) deficiency is also rare, asymptomatic, and can reduce resistance to infections. Case Report: A 45-year-old, Type 2 diabetic, African American male, presented to the Emergency Department with fever and cough. One week earlier, a dentist removed an infected tooth and prescribed 7 days of amoxicillin. One day before, he had fever (104 degrees), cough. and left upper quadrant abdominal pain. Pertinent Physical Exam: Vital Signs: 100.7 temperature; blood pressure 120/72, pulse 98, respiratory rate 20, oxygen saturation 97% on room air, normal oral exam, no cervical lymph enlargement, left upper quadrant tenderness. Pertinent Labs: WBC 16, 330, Hemoglobin 12.3, Platelets 417 K. Hepatitis panel, HIV, and sickle screen were negative Treatment: After blood cultures, he received intravenous (IV) vancomycin & piperacillin- tazobactam. Hospital Day (HD) 1: Contrasted Chest

CT revealed no pulmonary embolus, multiple infiltrates suspicious for pneumonia, and left upper abdominal quadrant-subdiaphragmatic loculated fluid. HD 2: Radiology drained 50 milliliters of purulent fluid and placed a drain from the subdiaphragmatic space and spleen from what appeared to be a splenic abscess. Hemoglobin fell to 10.1. HD 3: Hypoxia worsened, and he was transferred to the ICU on BiPAP. Admission blood cultures grew Candida glabrata. Intravenous micafungin was added to vancomycin and piperacillin-tazobactam. Repeat contrasted CT abdomen and pelvis showed residual left upper quadrant fluid after drainage. HD 4. No valvular vegetations were seen on transesophageal echocardiogram. Subdiaphragmatic spleen fluid grew streptococcus viridans, Candida glabrata and Klebsiella pneumonia. Antibiotics were transitioned to ceftriaxone; micafungin was continued. Patient remained hypoxic and required supplemental oxygen. HD 5: Daily blood cultures grew Candida glabrata. Infectious Disease consult recommended G6PD deficiency screen, G6PD RBCs = 3.97x10E6/ uL (normal 4.14-5.80x10E6/uL) and G6PD = 323 (normal 146-376), consistent with G6PD deficiency, previously unknown. HD9: He improved and repeat blood cultures were negative. The drainage catheter

was removed. He was discharged on 6 weeks of IV micafungin and IV ceftriaxone. Diagnosis: Splenic abscess and multilobe pneumonia. Follow Up; About one month after discharge, he returned with left upper quadrant pain and fevers. Abdominal-pelvic CT had a large splenic abscess (5.8cm x 4.8cm) and left side large empyema. He was transferred to a tertiary care facility for splenectomy and chest drainage. Comment: G6PD deficiency, predominantly affecting males (X-linked), is due to multiple gene mutations. While common (400 million people worldwide) it has a spectrum of disease severity. People with G6PD deficiency have increased susceptibility to infections. This G6PD patient displayed anemia and increased infection susceptibility with recurrent splenic abscesses. Splenectomy with appropriate antibiotics which this patient received is the standard for treatment.

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