Virginia Research Day 2021

SPLENIC ABSCESS AND MULTILOBE PNEUMONIA IN A PATIENT WITH G6PD DEFICIENCY Chelsea Dalfrey, DO, Ryan O’Connell, DO Sovah Health Internal Medicine Residency Program, Danville, VA

RC-16

Clinical Course: On admission, after blood cultures, he received intravenous (IV) vancomycin & piperacillin-tazobactam. Hospital Day 1 (HD1) Contrasted Chest CT revealed no pulmonary embolus, infiltrates suspicious for multifocal pneumonia, and left upper abdominal quadrant-subdiaphragmatic loculated fluid (Figure 1). The next day, 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 (Figure 2). Hemoglobin fell to 10.1. HD3: Hypoxia worsened, and he was transferred to the ICU on BiPAP. Admission blood cultures grew Candida glabrata. IV Micafungin was begun; vancomycin and piperacillin-tazobactam were continued. Hepatitis panel, HIV, and sickle screen were negative. Repeat contrasted CT abdomen and pelvis showed residual left upper quadrant fluid after drainage. HD4: 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. HD1-3 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), a mild G6PD deficiency, previously unknown. HD9: Repeat blood cultures were negative, oxygen need decreased. He was transferred out of the ICU; drainage catheter was removed

Background: Splenic abscess is rare, occurring in immunocompromised patients from hematogenous spread. Glucose-6-phospate dehydrogenase (G6PD) deficiency is also rare, usually asymptomatic, and which can reduce resistance to infections. Chief Complaint & History : 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. Past Medical History: Type 2 diabetes mellitus Medications : None Allergies: No known drug allergies Family History : Patient did not know of any family medical conditions. Review of Systems : Cough, shortness of breath, nausea, vomiting, diarrhea, fatigue, chills, fever, sore throat Vital Signs: : 100.7 temperature; blood pressure 120/72, pulse 98, respiratory rate 20, oxygen saturation 97% on room air Pertinent Physical Findings : Normal oral exam, no cervical lymph enlargement, left upper quadrant abdominal tenderness, & normal bowel sounds. Social History: Lives with family, performs ADLs independently. Smokes 1 pack per day, and denies alcohol and illicit drug use Pertinent Diagnostic Studies : WBC 16,330, Hemoglobin 12.3, Platelets 417 K Timeline of Important Laboratory Values: Hemoglobin: 12.3 (Day 0), 10.1 (Day 2)

Figure 1. Multifocal pneumonia

Figure 2: Splenic abscess (Yellow Arrow) on Abdominal CT

Conclusion: This patient displayed anemia and increased infection susceptibility with recurrent splenic abscess. Our patient had a splenectomy, with appropriate antibiotics, which is the standard treatment of splenic abscess. References: • Arese P, et al. Pathophysiology of hemolysis in glucose-6-phosphate dehydrogenase deficiency. Semin Hematol 1990;27:1-40. • Cappellini MD, et al. Glucose-6-phosphate dehydrogenase deficiency. Lancet . 2008 Jan 5;371(9606):64-74. doi: 10.1016/S0140- 6736(08)60073-2. Review. • Divyashree S, et al. Splenic Abscess in Immunocompetent Patients Managed Primarily without Splenectomy: A Series of 7 Cases . Perm J . 2017;21:16-139. doi:10.7812/TPP/16-139 • Frank J. Am Fam Physician . 2005 Oct 1;72(7):1277-1282. Discussion: 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. .

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