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442110

nneyJournal of Diagnostic Medical Sonography

JDMXXX10.1177/8756479312442110McKi

Case Studies

Splenic Abscess Detection


and Monitoring Using Sonography

Journal of Diagnostic Medical Sonography


28(4) 168172
The Author(s) 2012
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/8756479312442110
http://jdms.sagepub.com

Elizabeth Ruzicka McKinney, BS, RDMS1

Abstract
The finding of a splenic abscess is rare, with only 500 to 600 cases ever having been reported internationally. Prior
to the advent of sonography and computed tomography, the survival rate for an individual with a splenic abscess was
0%. Present-day real-time imaging with sonography allows for accurate diagnosis of an abscess in the spleen versus
rupture, hematoma, splenomegaly, or cyst within the spleen or left kidney. Until recently, the prescribed treatment
was splenectomy. The increased understanding of splenic abscess etiology and advancements in pharmacology have
allowed the treatment to progress from surgical removal of the entire spleen to draining the abscess using fine-needle
aspiration with the use of strong broad-spectrum intravenous antibiotics.
Keywords
splenic abscess, ultrasonography, sonography, sepsis

Abscess of the spleen is not a routinely seen finding. A


review of the literature shows that only 500 to 600 cases
have ever been reported internationally.1 The pathogenesis of splenic infections responsible for splenic abscess
is typically defined by five categories: (1) metastatic
hematogenous infection, including intravenous (IV)
drug use; (2) hemoglobinopathy; (3) immune system
suppression secondary to chemotherapy or human
immunodeficiency virus; (4) trauma; and (5) contiguous
site of infection.25 The most frequent agent of splenic
abscess is an infection with gram-positive cocci dominated by Enterobacteriaceae. When gram-negative
bacilli are the causative agent of the infection, the most
frequently represented are Klebsiella pneumoniae and
Escherichia coli.6 Most splenic abscesses are caused by
a source of infection originating from outside of the
affected organ. Sengupta and Mukhergi7 determined
that 70% of splenic abscesses were caused by infectious
sources external to the spleen such as amoebic dysentery, peritonsillar abscess, bacterial endocarditis, lung
abscess, appendicitis, or pneumonia. An additional 15%
were related to direct trauma to the spleen, and 10%
were a result of sepsis.
We present a case of splenic abscess secondary to urosepsis, an infection of the urogenital tract that occurs
when bacteria are introduced, which was detected and
monitored by sonography. In this case, a prior medical
procedure, a transrectal sonography-guided prostate
biopsy, allowed E coli to travel to the spleen via the
bloodstream.

Case Report
A man in his mid-50s underwent a transrectal sonographyguided prostate biopsy due to elevated prostate-specific
antigen (PSA). Bactrim, a preparation of sulfamethoxazole
and trimethoprim, had been given for perioperative prophylaxis. Four days after the procedure, the patient
returned to the emergency room (ER) with a high-grade
fever and abdominal pain. The urinalysis was positive for
E coli, and urosepsis was determined to be secondary to
the transrectal sonography-guided prostate biopsy.
Antibiotic therapy using IV vancomycin (a drug choice
usually reserved for treatment of bacterial infections
resistant to other drugs) was administered. Nineteen days
after the procedure, the patient presented a second time
to the ER with a moderate-grade fever, chills, rigors, and
increased abdominal pain in the left upper quadrant. A
complete abdominal sonographic examination was done
using a Philips IU22 system (Koninklijke, The Netherlands)
with a curved linear-array 6-MHz transducer that showed
an abscess in the spleen. The abscess was noted to be
located in the posterior spleen. Abscess volume of 90.4;
mL was calculated using the splenic volume calculation
1

Diagnostic Medical Ultrasound, School of Health Professions,


University of Missouri, Columbia, MO, USA
Corresponding Author:
Elizabeth Ruzicka McKinney, BS, RDMS, University of Missouri, 3805
North Cottonwood Court, Columbia, MO 65202, USA
Email: erm3m8@mail.missouri.edu

169

McKinney

Figure 1. Long view of splenic abscess, 6.40 cm length and


4.30 cm height, 15 days after diagnosis of Escherichia coli and
urosepsis secondary to a transrectal sonography-guided
prostate biopsy that was done 19 days prior.

Figure 3. Long view of splenic abscess, 3.30 cm length


and 1.66 cm height, 15 days after beginning treatment with
intravenous ceftriaxone 2 mg/d.

Figure 2. Transverse view of splenic abscess, 6.26 cm width,


15 days after diagnosis of Escherichia coli and urosepsis
secondary to a transrectal sonography-guided prostate biopsy
that was done 19 days prior.

Figure 4. Transverse view of splenic abscess, 2.81 cm


width, 15 days after beginning treatment with intravenous
ceftriaxone 2 mg/d.

package based on measurements of the abscess length


(6.40 cm), height (6.26 cm), and width (4.30 cm)
(Figures 1 and 2). The abscess had an oval, anechoic
appearance with well-defined borders and strong posterior enhancement. No inflammatory rim or isoechoic
infiltrations were detected. A peripherally inserted central
catheter line was established for the administration of
ceftriaxone, a third-generation cephalosporin antibiotic
with broad-spectrum activity against gram-positive and
gram-negative bacteria. After 14 days of 2 mg IV ceftriaxone daily, a 91% reduction of the abscess volume was
visualized on a follow-up sonogram (Figures 3 and 4). In

addition to its smaller size (3.30 2.81 1.70 cm; 8.07


mL), the abscess had also lost its anechoic appearance.
The shape was more round than oval, the borders were
not as well defined, and most of the abscess was
isoechoic to slightly hypoechoic compared with the
spleen. The location of the abscess was isolated to the
most posterior section of the spleen with only moderate
posterior enhancement. The patient continued ceftriaxone antibiotic therapy for another 14 days, at which time
a repeat sonogram showed an additional 1% reduction in
volume. The abscess was measured as 2.92 2.23 2.14
cm (7.30 mL), with only a slight posterior enhancement

170

Journal of Diagnostic Medical Sonography 28(4)

Figure 5. Long view of splenic abscess, 2.92 cm length


and 2.14 cm height, 30 days after continued treatment with
intravenous ceftriaxone 2 mg/d.

Figure 7. Long view of splenic abscess, 1.96 cm length and


1.67 cm height, 28 days after oral administration of augmentin
and 30 days of treatment with intravenous ceftriaxone 2 mg/d.

Figure 6. Transverse view of splenic abscess, 2.23 cm


width, 30 days after continued treatment with intravenous
ceftriaxone 2 mg/d.

Figure 8. Transverse view of splenic abscess, 2.19 cm width,


28 days after oral administration of augmentin and 30 days of
treatment with intravenous ceftriaxone 2 mg/d.

(Figures 5 and 6). An additional antibiotic treatment with


augmentin, twice a day, for 28 days was prescribed. The
abscess was noted to be further reduced in size to 1.96
2.19 1.67 cm (3.73 mL), a 96% reduction of the original abscess. Its appearance was isoechoic to the spleen
with no posterior enhancement (Figures 7 and 8). The
remaining slightly echogenic borders were the only
detectable evidence of the abscess.

such as endocarditis, dental infections, or, as in the


case presented, urosepsis. Sepsis will occur when an
infection leads to systemic inflammatory response
syndrome,10 the dysregulation of the inflammatory
response with excessive and uncontrolled release of proinflammatory mediators. It can lead to apnea, abnormal
organ function, changes in mental function, decreased
urine output, and disseminated intravascular coagulopathy, forming microthrombi or other blood abnormalities.
If severe, sepsis can lead to septic shock and hypotension, hypoperfusion of one or more organs, and eventually end-organ ischemia. Early detection is essential for
a favorable prognosis, and treatment with antibiotics
should be started as soon as possible after diagnosis. For
every hour of delay in beginning treatment with the
correct antibiotic therapy, there is a correlating 7% rise
in mortality.11

Discussion
Splenic abscess is a rare finding caused by infectious
sources external to the spleen, direct trauma to the
spleen, or a result of sepsis.3,4,69 They are found more
often in adults as a singular unilocular abnormality and
more often in children as multiple or multilocular abnormalities. Sepsis may be secondary to a variety of sources

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McKinney
In the case presented, a splenic abscess was a result of
a prior medical procedure, a transrectal sonographyguided prostate biopsy, which allowed E coli to become
translocated via the bloodstream to the spleen. A potential
contributing factor in this particular case was the patients
prior history of chronic obstructive pulmonary disease
(COPD) and osteoarthritis. He was taking albuterol to
help manage the COPD, a steroid that reduces the bodys
inflammatory response. This may have reduced the ability of the patients immune system to respond to the
infection resulting from the transrectal sonographyguided prostate biopsy.
Transrectal sonography-guided prostate biopsy is frequently associated with minor complications (60%79%
of cases) but rarely with major complications that require
hospitalization (0.4%3.5% of cases).1214 Early complications of transrectal sonography-guided prostate biopsy
include hematuria (70.8%) and rectal bleeding (8.3%).
Delayed complications of transrectal sonography-guided
prostate biopsy, at 3 to 7 days postbiopsy, include persistent hematuria (47.1%), vague pelvic discomfort (13.2%),
hematochezia (rectal bleeding) (9.1%), dysuria (9.1%),
and hematospermia (blood in the semen) (9.1%). Even
though complications from transrectal sonography-guided
prostate biopsies are fairly common, a study by Paterson
et al12 determined that only 0.23% of 4749 outpatients in
whom transrectal sonography-guided prostate biopsies
were performed between 2001 and 2006 were positive for
urosepsis. A recently tested protocol included obtaining
colon swabs from the patient prior to the transrectal
sonography procedure to determine the sensitivity of the
flora.14 Antibiotic prophylaxis was then selected to reflect
the organisms encountered and their susceptibilities,
decreasing the infective complications.
Sonography was an essential element in the diagnosis
and surveillance during the course of treatment in this
case of splenic abscess. Sonography allowed a noninvasive, rapid accurate diagnosis of an abscess in the spleen
versus possible diagnoses of rupture, hematoma, splenomegaly, or cyst. The ability of sonography to monitor the
splenic abscess allowed the treatment with strong broadspectrum IV antibiotics to run its course without the need
for splenectomy or other invasive procedures.

Conclusion
The use of imaging modalities such as sonography can
confirm or rule out a splenic abscess in a febrile patient
with left upper quadrant pain. If such an abscess is not
detected and treated with antibiotics early, it may become
severe and rapidly life-threatening with a mortality rate
up to 47%.9 The ability of sonography to monitor the
effectiveness of the antibiotics being administered has

allowed successful pharmacologic treatment of splenic


abscesses and avoided invasive procedures and splenectomy with its surgical risks and long-term consequences.
Acknowledgments
The author thanks Sharlette D. Anderson, MHS, RDMS, RVT,
RDCS, and Ecaterina M. Hdeib, MA, RDMS, for their encouragement and help in writing and editing this case study.

Declaration of Conflicting Interest


The author declared no potential conflicts of interest with respect
to the authorship and/or publication of this article.

Funding
The author received no financial support for the research and/or
authorship of this article.

References
1. Carbonell AM, Kercher KW, Mathews BD, Joels CS,
Sing RF, Heinford BT: Laparoscopic splenectomy for
splenic abscess. Surg Laparosc Endosc Percutan Tech
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2. Phillips GS, Radosevich MD, Lipsett PA: Splenic abscess:
another look at an old disease. Arch Surg 1997;132:13311336.
3. Ghidirim G, Rojnoveanu G, Misin I, Gagauz I, Gurghis R:
Splenic abscess-etiology, clinical and diagnostic features.
Chirurgia (Bucar) 2007;102:309314.
4. Ulhaci N, Meteoglu I, Kacar F, Ozbas S: Abscess of the
spleen. Pathol Onocol Res 2004;10:234236.
5. Sieler LA: Sonography of the spleen: a review. J Diagn
Med Sonography 1987;3:69.
6. Westh H, Reines E, Skibsted L: Splenic abscesses: a review
of 20 cases. Scand J Infect Dis 1990;22(5):569573.
7. Sengupta D, Mukhergi B: Ameobic abscess of the spleen.
J Ind Assoc 1975;64:4547.
8. Chang KC, Chuah SK, Changchien CS, et al: Clinical
characteristics and prognostic factors of splenic abscess:
a review of 67 cases in a single medical center of Taiwan.
World J Gastroenterol 2006;12(3):460464.
9. Alvi AR, Kulsoom S, Shamsi G: Splenic abscess: outcome and prognostic factors. J Coll Physicians Surg Pak
2008;18(12):740743.
10. Bone R, Balk R, Cerra F, et al: Definitions for sepsis and
organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference
Committee. Chest 1992;101(6):16441655.
11. Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: international guidelines for management
of severe sepsis and septic shock: 2008. Crit Care Med
2008;36(1):296327.
12. Paterson RF, Buckley AR, Bryce E: TRUS and prostate
biopsy sepsis. http://www.urologyrounds.com/files/PDF/
jan-30-08.pdf

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13. Jesitus J: Prostate biopsy infections major concern
for urologist. Urol Times. 2011 May 15. http://www.
modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=722434&sk=&date%OA%09%09%09&
page=2

Journal of Diagnostic Medical Sonography 28(4)


14. Madden T, Doble A, Aliyu SH, Neal DE: Infective complications after transrectal ultrasound-guided prostate
biopsy following a new protocol for antibiotic prophylaxis aimed at reducing hospital-acquired infections. BJU
Int 2011;108(10):15971602.

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JDMXXX10.1177/8756479312452706JDMS
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Article: Splenic Abscess Detection and Monitoring


Using Sonography
Author: Elizabeth Ruzicka McKinney, BS, RDMS
Category: Abdomen
Credit: 1 SDMS CME credit

c. Four
d. Five

Objectives: After studying the article titled Splenic


Abscess Detection and Monitoring Using Sonography,
you will be able to:

2. The most frequent gram-negative bacillus causing


splenic abscess is
a. Pseudomonas aeruginosa
b. Helicobacter pylori
c. Klebsiella pneumoniae
d. Escherichia coli

1. Describe the common pathogenic mechanisms for


splenic infections.
2. Discuss the sonographic features of a splenic
abscess.
3. Develop a sonographic follow-up protocol for
assessing the treatment of a splenic abscess.

3. What percentage of the time are splenic abscesses


caused by infectious sources external to the spleen?
a. 70%
b. 75%
c. 80%
d. 85%

1. Possible pathogenesis for splenic infections


resulting in splenic abscess is typically defined by
how many categories?
a. Two
b. Three

4. Early sonographic features of a splenic abscess


include the following except
a. Inflammatory rim
b. Well-defined borders
c. Oval shape
d. Posterior enhancement

174

Journal of Diagnostic Medical Sonography 28(4)

5. Late sonographic features of a splenic abscess


include the following except
a. Rounded shape
b. Iso/hypoechoic interior
c. Well-defined borders
d. Posterior enhancement

8. For every hour of delay in the onset of treatment


for a splenic abscess, morality increases by
a. 3%
b. 5%
c. 7%
d. 9%

6. Splenic abscesses in children are most likely to


appear as a
a. Unilocular abnormality
b. Multilocular abnormality
c. Singular abnormality
d. Hyperechoic, irregular abnormality

9. The most common complication of sonographyguided prostate biopsy is


a. Pelvic discomfort
b. Hematuria
c. Rectal bleeding
d. Dysuria

7. If not treated early and aggressively, the mortality secondary to splenic abscess can be as high
as
a. 35%40%
b. 45%50%
c. 55%60%
d. 65%70%

10. Urosepsis occurs with approximately what frequency following sonography-guided prostate
biopsy?
a. 2%
b. 1%
c. 0.5%
d. 0.25%