A sting in the tail of Hurricane Charley

Abstract

A 76-year-old man with maturity onset diabetes mellitus, hypercholesterolaemia, hypertension and a history of coronary artery bypass surgery was well until his home in Punta Gorda was devastated by Hurricane Charley. He and his wife had remained in their home as it was torn apart by the ferocious wind and rain but amazingly they survived. He received numerous insect bites while searching among the flooded ruins. Within 48 hours, he became unwell, with fatigue, lethargy, myalgia, rigors and anorexia. Despite deteriorating, he did not seek medical attention until returning to the UK 3 weeks later by which time he had lost 2 stones in weight. He had received oral cephalosporin but this was not based on the evidence of infection or the result of any investigation. On examination, he looked unwell with a sallow complexion. He was initially apyrexial. An abdominal examination revealed fullness but no palpable mass. Investigations showed leucocytosis 19.0 × 109/litre – 95% neutrophils. C-reactive protein (CRP) was 160 mg/litre. Abdominal ultrasound confirmed splenomegaly with a suggestion of an intrasplenic mass. Computed tomography (CT) scanning demonstrated a large multilobulated, low density mass within the spleen extending close to the capsular surface, indicative of an abscess (Figure 2). Five days after cessation of antibiotics, he was pyrexial (37.8°C) and blood cultures yielded Gram-negative bacillus, Escherichia coli. Echocardiography showed no evidence of infective endocarditis. Percutaneous drainage of the intrasplenic abscess using a pigtail catheter revealed 500 ml of chocolatebrown coloured pus. A Gram stain showed Gram-negative bacilli and culture of the aspirate revealed Escherichia coli sensitive to ceftriaxone. He was treated with a single intravenous dose of gentamicin 360 mg, intravenous ceftriaxone 1 g twice daily for 2 weeks and metronidazole 500 mg three times daily for 2 weeks and the abscess resolved. He improved rapidly and 7 days after draining the abscess, the CRP fell to 13 mg/litre and the leucocyte count to 6.9 × 109/litre. Subsequent CT scanning showed resolution of the splenic abscess. Although genitourinary investigation revealed no abnormality, a barium enema showed a 5 mm polyp and diverticula in the sigmoid colon.