Multiple splenic abscesses in a child with enteric fever treated by percutaneous aspiration and antibiotics

Multiple splenic abscesses are a condition associated with high mortality if there is delay in the diagnosis and initiation of specific treatment. Salmonella typhi as an etiological cause of multiple splenic abscesses is a distinct rarity. In the past treatment for splenic abscess including in enteric fever was splenectomy however; conservative treatment by percutaneous drainage is increasingly being reported for isolated splenic abscess and now for multiple splenic abscesses. We report a child with enteric fever who presented with multiple splenic abscesses and was successfully treated by percutaneous aspiration and antibiotics.

Keywords: Enteric fever, multiple splenic abscesses, percutaneous aspiration

Splenic abscess is rare in children. An incidence of 0.2 to 0.7% has been reported in autopsy-based studies. ^[1] Enteric fever as a cause of this condition is even less common with only few case reports in the literature. The diagnosis of splenic abscess is often delayed in children due to its rarity and non-specific clinical features.

A nine-year-old male child presented with the complaints of high grade fever, pain in abdomen and abdominal distension for 7 days. Child was having non-bilious vomiting and decreased oral acceptance for 2 days. The child was toxic looking with high grade fever, had weight of 23 kg, height of 131 cm, respiratory rate of 42/min, heart rate of 129/min and blood pressure was 84/44 mmHg. The child had some pallor. There was no jaundice, dehydration, lymphadenopathy, bony tenderness and pedal edema. Abdominal examination revealed tender hepatomegaly of 6 cm and tender splenomegaly of 3 cm below costal margin. Marked guarding and tenderness was present all over abdomen. Shifting dullness was positive and bowel sounds were present. Chest examination revealed bilateral decreased air entry with dull percussion note. The child had low initial blood pressure which responded to fluid resuscitation. Urgent X-ray of abdomen and chest was normal. Hemogram showed hemoglobin of 8.6 gm%, total leukocyte count was 2900/mm ³ , platelet count 95000/mm ³ . Serum electrolytes, serum amylase, serum lipase, kidney function test were normal. Peripheral smear for malaria, Dengue serology and rapid malarial antigen test for malaria parasite were negative. Liver function test showed deranged enzymes only. PTTK and PT were also done with INR of 1.4. Widal test was positive in 1:320 dilution titers for TO, 160 for TH and 160 for AH and BH. Typhi-dot IgM was positive. Blood culture was negative.

Ultrasound of abdomen showed enlarged liver with no hypoechoic areas. Spleen was enlarged along with multiple irregular hypoechoic areas near lower pole largest one measuring 1.6 × 1.1 cm suggestive of evolving abscess with minimal bilateral pleural effusions with free fluid in abdomen. Contrast-enhanced CT scan of abdomen showed multiple splenic abscesses, largest one measuring 2 × 1.3 cm, there was no perisplenic collections [Figure 1] and [Figure 2]. Pleural tap and ascites tap revealed no cells on microscopy and transudative biochemistry. Gram staining, AFB staining and culture of plural and ascites tap were negative. Mantoux test, HIV serology, hydatid cyst serology and sickling test was negative. Immunoglobulin profile was normal.

The child was given a blood transfusion and given injection ceftriaxone, amikacin and metronidazole. However, antibiotics were later changed to Meropenem and Vancomycin as high grade fever and toxicity persisted. An ultrasound-guided splenic tap was done with all aseptic precautions. Three abscess cavities were tapped and 33 ml hemorrhagic fluid was aspirated. Cytology of the aspirate revealed pus cells and RBCs. Pus culture was sterile. Child responded and became afebrile 18 days after admission. Child’s hepatosplenomegaly regressed and hemogram normalized. The child was given changed antibiotics for 4 weeks and then discharged. Ultrasound abdomen was repeated before discharge and revealed non-liquefied cavities of similar size as before. Further, follow-up ultrasound of the child after one month of discharge showed few linear and nodular calcifications at lower pole of spleen with 16 × 8 mm hypoechoic area at inferior pole suggestive of healed abscess.

Splenic abscesses are rare entity in children. It is postulated that phagocytic activity of the reticuloendothelial system and leucocytes in the spleen protect against abscess formation. However, impaired host defenses, metastatic pyogenic infection such as infective endocarditis, splenic trauma, hemoglobinopathy (sickle cell anemia), leukemia and immunodeficiency predisposes to splenic abscess. ^[2] Common etiologic agents of splenic abscess are staphylococci, streptococci, enterococcus and gram-negative bacteria e.g. Klebsiella, Escherichia coli and pseudomonas. Candida and atypical mycobacteria is also reported in immunocompromised patients. ^[3] Only few reports have reported Salmonella typhi as causative agent of splenic abscess. ^[4],[5]

Splenic abscess are either solitary (SSA) or multiple (MSA). Incidence of MSA has been reported to be 24.8% in a case series. ^[6] In the past, treatment of splenic abscess was splenectomy and antibiotics. Current treatment reported by various authors advocates conservative approach for isolated splenic abscess by percutaneous drainage procedures due to importance of preserving splenic functions in children wherever possible. It has been found to be effective, has lesser morbidity and no incidence of post splenectomy complications like sepsis and poor immunological response. ^[7],[8] A success rate of up to 68% has been reported by ultrasound-guided drainage of splenic abscess and only complication reported was the development of a sub-capsular hematoma following drainage with no hemodynamic compromise. ^[9] However, splenectomy partial or total is still advocated by some authors for failed percutaneous abscess drainage, multi-loculated and multiple splenic abscess. ^[10] Recently, Choudhary SR et al managed all SSA greater than 3 cm in size and 4 cases of MSA by ultrasound-guided percutaneous aspiration and antibiotics. No procedure-related complication was noted and all patients recovered. From their experience, they concluded that percutaneous drainage was effective in management of SSA as well MSA including cases associated with typhoid fever where traditional management described is splenectomy. It should be the first line of choice in treatment for both MSA and SSA. ^[11] The contraindications to percutaneous drainage include multi-loculated abscess, uncontrolled coagulopathy, poorly defined abscess on CT scan or ultrasonogram, hydatid cyst, inconvenient location such as upper pole and hilum and diffuse ascites. Duration of antibiotic therapy has not been well defined to treat multiple splenic abscesses. The duration of antibiotics by authors has varied from 10 days after post-surgical drainage to 12 weeks. ^[12] We gave antibiotics in our case for 4 weeks.

In the present case, both blood culture and pus culture was sterile. This could be because of early initiation of antibiotics. Blood culture positivity is reported to be only 48% ^[13] and pus aspirate culture positivity to be 14-73% cases ^[6],[11] in splenic abscess. Typhidot IgM test positivity has sensitivity of 92% and specificity of 87.5% in detecting enteric fever, whereas blood culture positivity in even uncomplicated enteric fever is 68%. ^[14]

In conclusion, splenic abscess is a rare and unrecognized complication of enteric fever and should be treated with antibiotics with or without percutaneous aspiration as a first line of treatment.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.98628

[Figure 1], [Figure 2]