CASE REPORT

Multiple Splenic Abscesses in 2 Patients with Myelodysplastic Syndrome
Goichi Tatsumi, Mitsumasa Watanabe, Hitomi Kaneko, Hirokazu Hirata and Mitsuru Tsudo

Abstract
Splenic abscess is a rare clinical condition with a high mortality rate. Multiple splenic abscesses, rather than a solitary abscess, are present in immunocompromised states including hematological malignancies. As symptoms of splenic abscesses, fever and abdominal pain, are non-specific, timely and adequate use of imaging studies is crucial for early diagnosis. We report the cases of 2 patients with myelodysplastic syndrome and multiple splenic abscesses. Notwithstanding the higher mortality rate of patients with multiple splenic abscesses as compared with those with a solitary splenic abscess, we successfully treated the 2 patients by using antibiotic therapy and fine needle aspiration. Key words: multiple splenic abscess, myelodysplastic syndromes, antibiotics, fine needle aspiration (Intern Med 51: 1573-1577, 2012) (DOI: 10.2169/internalmedicine.51.7267)

Introduction
Aging societies are characterized by an increasing number of patients with immunocompromised states such as hematological malignancies. These patients are at great risk of lifethreatening infections. Splenic abscess is a rare clinical condition with a reported frequency of 0.14-0.7% in an autopsy series in Europe (1, 2). However, it carries a high mortality rate because of late diagnosis (1-8). Moreover, the detection frequency is increasing because of the current sophisticated imaging techniques and the growing number of immunocompromised patients. Predisposing conditions other than immunodeficiency include splenic trauma (in which case the splenic abscess develops weeks or months later), metastatic hematogenous infections, and contiguous sites of infection (5, 6). Notably, immunocompromised patients often have multiple splenic abscesses rather than solitary (9). Here, we report 2 cases of multiple splenic abscesses in patients with myelodysplastic syndromes (MDS) successfully treated with antibiotic therapy and fine needle aspiration. Case 1

Case Reports

A 50-year-old woman was admitted to our hospital with complaints of fever, malaise and dyspnea on exertion. These symptoms occurred quite suddenly. On examination, the temperature was 37.9℃ and the oxygen saturation was 98% in ambient air. There was no current norpast history of splenomegaly and no abdominal tenderness. Her past medical history included MDS with refractory anemia and rheumatoid arthritis. When she was 41 years old, her annual medical check-up revealed mild anemia and leukocytopenia, and MDS with refractory anemia was diagnosed based on bone marrow examination. Rheumatoid arthritis was diagnosed when she was 48 years old, and her current treatment included 10 mg/day of prednisolone and 1,000 mg/day of salazosulfapyridine. Her recent blood counts showed mild pancytopenia (white blood cells 3,000/ mm3 with 67% granulocytes and 23% lymphocytes; hemoglobin 7.6 g/dL; and platelet counts 92,000/μL), but she had not been prescribed any medication for MDS. Although there were few abnormal physical findings, chest radiography showed the presence of left pleural effu-

Department of Hematology, Osaka Red Cross Hospital, Japan Received for publication January 10, 2012; Accepted for publication March 5, 2012 Correspondence to Dr. Goichi Tatsumi, go.tatsumi@osaka-med.jrc.or.jp

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and gastric wall. Contrast material-enhanced abdominal computed tomography showed left pleural effusion and multiple low attenuation areas in the spleen. kidneys. kidneys.Intern Med 51: 1573-1577. including α-streptococci. A few days before admission. Neisseria species. the erythema disappeared quickly. 1a. she had a lung abscess that was successfully treated with antibiotic therapy elsewhere. c. were normal. Computed tomography of the abdomen revealed multiple abscesses (arrows) in the spleen. b. We also performed upper gastrointestinal endoscopy and found 2 swollen lesions at the gastric fundus. An endoscopic image of the upper abdomen. Several months later. She has remained asymptomatic ever since. After administration.9 g/dL). 2). the patient was initially treated with intravenous imipenem-cilastatin. a. As these symptoms were thought to be a relapse of Behçet’s disease. but fever persisted. We suspected that these findings resulted from abdominal infection and performed imaging studies. Laboratory data disclosed leukocytosis (white blood cells 13. After treatment with corticosteroids and immunosuppressive agents. Cultures from blood and urine samples were negative. Yellow pus oozed out from these lesions after biopsies were performed (Fig. but samples obtained from the abscesses in the gastric wall revealed the presence of multiple types of bacteria. Although fever and C-reactive protein levels fluctuated after treatment. including liver and renal functions. After diagnosis. Collectively. potassium iodide was administered orally. and gastric wall (Fig. Other data. an elevated C-reactive protein level (11 mg/dL). and gastric wall. elevated C-reactive protein 1574 . and progressive anemia (hemoglobin 6.560/mm3 with 93% of segmented forms). Acinetobacter species and anaerobic gram-negative cocci. and fluconazole. left abdominal pain developed and worsened. sion.7267 a b c Figure 1.600/ mm3 with 88% granulocytes). they subsided gradually with the addition of van- comycin or teicoplanin (Fig. Case 2 A 52-year-old woman was admitted to our hospital with fever and left abdominal pain. There was tenderness in the left upper quadrant of the abdomen but no splenomegaly and no past history of splenomegaly. her temperature was 39.1℃. Cardiac ultrasonography identified no vegetation.51. Laboratory data revealed a left shift of white blood cells (7. She had been diagnosed with intestinal Behçet’s disease at the age of 26 years. accompanied by erythema nodosum. Nine months before admission. 2012 DOI: 10. Imaging findings of case 1.2169/internalmedicine. fever recurred. On examination. Thereafter. kidneys. b). tobramycin. Abscesses completely disappeared from computed tomography scans (performed on hospital day 49). these findings indicated that multiple abscesses were formed in the spleen. she was referred to our hospital for further evaluation. she had achieved remission and had not received medication since 1991. 1c).

 Imaging findings of case 2. 2012 DOI: 10. BT: body temperature.Intern Med 51: 1573-1577.51. Neu: neutrophil a b c Figure 3. level (12. 3a. and yellow pus was aspirated. Abdominal computed tomography revealed 2 non-enhancing hypo-dense areas (44 and 6 mm) in the spleen (Fig. Cardiac ultrasonography identified no vegetation.5 mg/dL). IPM: imipenem. Levels of vitamin B12 and folate were normal. WBC: white blood cells. 3c). Ultrasonography plane during fine needle aspiration of the larger abscess. Ultrasonography-guided fine needle aspiration was performed in the larger low echoic area of the spleen (Fig. c. Hb: hemoglobin. CRP: C-reactive protein. FCZ: fluconazole. DRPM: doripenem.7267 Figure 2. VCM: vancomycin. Clinical course of case 1. Computed tomography of the abdomen revealed 2 abscesses (arrows) in the spleen.9 g/dL with mean corpuscular volume of 106 fL). a. 1575 . TOB: tobramycin. b.2169/internalmedicine. TEIC: teicoplanin. and macrocytic anemia (hemoglobin 8. b).

The most common symptom of splenic abscess is fever. Therefore. In the present cases. 12). Abscesses had completely disappeared from computed tomography scans 2 months later. percutaneous fine needle aspiration or catheter drainage. After treatment. Chang et al. and C-reactive protein levels soon improved. Furthermore. (9) reported that poor prognostic factors include multiplicity. In contrast. She was discharged on hospital day 19 with oral antibiotics. On cytogenetic analysis. She has been found healthy with mild macrocytic anemia and is hitherto free from all referred symptoms. It typically tends to develop in patients with diabetes mellitus and infectious endocarditis. 0/20 metaphase cells were abnormal. her temperature. The triad of fever.000/mm3 with 1. MEPM: meropenem. Both of the present patients had multiple splenic abscesses. 12). macrocytic anemia persisted even after inflammation subsided sufficiently. However. 10). These agents are similar to the common pathogens of hepatic abscess (13). 10. 10. Case 2 had no previously known history of malignancy but was diagnosed with MDS after further evaluation of persisting macrocytic anemia. especially hematological malignancies. Case 1 had a history of MDS and cultures from abscesses contained gram-negative rods.7267 Figure 4. abdominal pain. but we should mention that splenic abscesses might also be triggered by autoimmune diseases and the use of steroids. The total number of nucleated cells was 140. These conditions alone were not reported to be a risk factor for multiple splenic abscesses. appropriate management can markedly decrease mortality to 14% (4. The major causative agents are gram-negative rods and fungal infection is increasing in frequency (9. and the diagnosis of splenic abscess was not possible by physical examination alone. 5). rheumatoid arthritis treated with steroids in case 1 and Behçet’s disease in case 2. left upper quadrant pain and tender mass has been suggested by Sarr and Zuidema as the presenting complex of splenic abscess (11). we report the successful treatment of 2 cases of multiple splenic abscesses in patients with MDS and underline the importance of early diagnosis with imaging techniques. Discussion Splenic abscess. and a high Acute Physiology and Chronic Health Evaluation (APACHE) II score. both patients had additional immunosuppressive conditions. antibiotic treatment 1576 . 5. MDS with refractory anemia was also diagnosed. However. The most common pathogenic agents are enteric gramnegative rods. 7-9). 9. Bone marrow biopsy and aspiration performed on hospital day 16 showed dysplasia in neutrophils and megakaryocytes. which include Escherichia coli and Klebsiella pneumoniae. Solitary splenic abscesses are often seen in patients with no underlying malignant disease. these symptoms are nonspecific and not always present simultaneously (4. multiple splenic abscesses are often seen in patients with underlying malignancies. and samples obtained from the abscess developed no bacteria on culture. 9). Therefore. which is a ―rare clinical condition first reported in the writings of Hippocrates (3). which was quite specific to MDS (Fig. 5. followed by abdominal pain and nausea (4. The causative agents are usually a single organism and the majority is reported to be Escherichia coli or Streptococci species (9). followed by Streptococci and Staphylococci (5. Treatment of splenic abscesses involves antibiotic therapy ―alone or in conjunction with splenectomy. 2012 DOI: 10. in part because both infections are frequently caused by hematogenous seeding in the setting of systemic infections. with a reported sensitivity of 98% (9).2169/internalmedicine. Indeed. probably because of prior antibiotic treatment. 4). 5). Clinical course of case 2. ABPC/SBT: ampicillin/ sulbactam. which is designed to measure the severity of disease and risk of death.51. Percutaneous drainage is advantageous in terms of maintaining proper immunological function. 14). both computed tomography and ultrasonography are effective in detecting splenic abscesses.2% of blasts. Indeed. splenic abscess should be considered in the differential diagnosis of patients with fever of unknown origin. and avoiding overwhelming post-splenectomy infections (4.Intern Med 51: 1573-1577. Splenectomy has long been considered the standard treatment. but recent evidence indicates that percutaneous drainage is also a reliable technique with a high therapeutic success rate (67100%) (5. Splenic abscesses can be classified into 2 types: solitary and multiple. ―has a high mortality rate (up to 47%) among patients who do not receive adequate antibiotic treatment. Abscesses also decreased in size (Fig. Cultures from blood and urine samples were negative. On the other hand. exempting critically ill patients from surgery. gram-negative rod infection. Here. SBTPC: sultamicillin Splenic abscesses were finally diagnosed. BMA: bone marrow aspiration. 6. the cases herein reported did not fulfill the triad.

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