J R Soc Med 2005;98:474-475
doi:10.1258/jrsm.98.10.474
© 2005 Royal Society of Medicine
An apparent splenic abscess
M T Huggett
A Howieson
C Wakefield
P C Gartell
Royal Hampshire County Hospital, Winchester SO22 5DG, UK
Correspondence to: Mr P C Gartell
Despite the involvement of six specialties, the cause of an apparent
splenic abscess eluded diagnosis until death.
CASE HISTORY
A man of 68 reported anorexia, nocturnal sweats and left upper quadrant
pain. On examination he was cachectic, with a mass in the left hypochondrium
and signs of a left pleural effusion. There was no peripheral lymphadenopathy.
Haemoglobin was 8.1 g/dL with a normocytic, normochromic picture. The white
cell count was within normal limits and a blood film was unremarkable.
C-reactive protein, urea and electrolytes and liver function tests were all
normal. Blood and urine cultures yielded no growth. CT revealed a lesion in
the spleen 22 cm in maximum diameter and consistent with a fluid collection
(Figure 1). A large left-sided
pleural effusion was also noted, without evidence of mediastinal or abdominal
lymphadenopathy. Malignant disease was suspected but pleural fluid repeatedly
showed only chronic inflammatory cells. Upper gastrointestinal endoscopy, bone
marrow biopsy, and plasma and urine electrophoresis were likewise
negative.
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Figure 1. Initial CT showing apparent fluid collection in spleen. Note simple
liver cysts of similar density
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The patient, initially admitted under the care of the gastroenterology
team,
was then discussed at a surgical–medical multidisciplinary
meeting
with a view to splenectomy, both for diagnostic and
therapeutic purposes. On
revisiting the history it was then
brought up that there had been a suggestion
of a blow to the
patient's left upper quadrant after he had fallen
heavily onto
the handles of his wheelbarrow some months before the start
of
his symptoms. The consensus was that the lesion in the spleen
might be an
aseptic collection, perhaps a liquefied haematoma.
There was a general
reluctance to proceed directly to splenectomy
in view of the patient's
frailty, and percutaneous drainage
was mooted. This was done under CT guidance
and a pigtail drain
was inserted. Fluid with the appearance of frank pus was
drained
but no organisms were seen on microscopy and cultures were negative.
The
drain was left
in situ for three weeks and continued to yield
small
quantities but the patient did not improve. Repeated examinations
of
fluid samples were unrewarding. On further CT the collection
had increased in
size and density and a lesion was seen at the
apex of the right lung.
Abdominal lymphadenopathy was not evident.
In an effort to obtain a tissue
diagnosis, the lung lesion was
approached via flexible bronchoscopy but biopsy
proved impossible
and washings were negative for malignant cells. Thoracoscopy
and
biopsy were proposed but the patient died as he was being transferred
to a
cardiothoracic unit. At necropsy he was found to have a
diffuse B-cell
lymphoma involving the spleen, stomach, lower
lobe of the left lung and apex
of the right lung.
COMMENT
Non-Hodgkin lymphoma can show itself anywhere in the body but we have found
only one previous report of it mimicking a splenic
abscess.1,2
Although our initial clinical diagnosis of haematological malignancy
ultimately proved correct, it was impossible to confirm during life. The story
of possible splenic trauma, raising an alternative diagnosis of splenic
haematoma and collection, turned out to be irrelevant. Splenic abscesses are
uncommon and tend to occur in the
immunocompromised.3
On drainage they usually yield frank pus, and this is what we appeared to
obtain; in retrospect this must have been necrotic tumour material.
REFERENCES
- Souhami R, Tannock I, Hohenberger P, Horiot J-C eds.Oxford Textbook of Oncology, 2nd edn.
Oxford: Oxford
University Press, 2001:2347
-76
- Abraksia S, Kumar PD, Kasal J. Two unusual lymphomas. J
Clin Oncol 2000;18:3731
-3[Free Full Text]
- Chiang IS, Lin TJ, Chiang IC, Tsai MS. Splenic abscesses: review of
29 cases. Kaohsiung J Med Sci2003; 19:510
-15[Medline]
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