Klebsiella splenic abscess complicating Plasmodium vivax malaria.

Abstract

To the Editors: Plasmodium vivax infection can be associated with splenic rupture during acute infection1 and splenic infarction. Splenic abscess is unique to Plasmodium falciparum infection and has been rarely reported.2 Abscess formation is presumed to be caused by infection of hematoma and infarction of the spleen resulting from repeated malarial infections.3,4 We report a child with P. vivax malaria complicated by splenic abscess who was successfully treated. Case: A 12-year-old boy presented with fever with chills for 8 days and vomiting for 1 day. He was diagnosed to have P. vivax malaria based on a rapid antigen detection card test and was treated with chloroquine before presentation to us. He had no skin rash, bleeding from any site, irritability, seizures, loss of consciousness, jaundice or altered urine color. On examination his vital signs were normal. He had mild hepatomegaly and splenomegaly. The rest of the systemic examination was unremarkable. Investigations revealed hemoglobin of 12 g/dL, a total leukocyte count of 15,900/cumm with neutrophils 84%, lymphocytes 10% and monocytes 6% and a platelet count of 66,000/cumm. Peripheral blood smear showed P. vivax gametocytes. Blood culture was sterile, and Widal test was negative. He was treated with artesunate 2.4 mg/kg given intravenously and at 12 and 24 hours followed by 2.4 mg/kg once daily orally for 7 days and doxycycline 3.5 mg/kg once daily for 7 days. He was afebrile by day 3 and was discharged from hospital. He was also given 0.25 mg/kg of primaquine for 14 days. He was admitted again 9 days later with recurrence of fever 4 days after discharge. Reevaluation of his peripheral blood smear did not reveal any malarial parasites. A bone marrow aspiration and biopsy were done in view of persisting fever, which showed mildly hyper cellular marrow with hemozoin pigments indicative of the recent malarial infection and no other abnormalities. Ultrasonography of the abdomen revealed splenomegaly (10.9 cm) with a heterogeneous cystic lesion measuring 26 × 24.8 mm with an estimated 8 mL volume of pus. An ultrasound guided aspiration of the abscess was performed. The pus culture grew Klebsiella species resistant to amoxicillin/clavulanate, piperacillin/tazobactam, levofloxacin, cefpodoxime, chloramphenicol, imipenem and meropenem, intermediately susceptible to amikacin and susceptible to cotrimoxazole and gentamicin. The immunoglobulin profile had age specific normal values. Nitro blue tetrazolium chloride (NBT) test showed normal neutrophilic function and the test for HIV was negative. He was treated with sulfamethoxazole 800 mg and trimethoprim 160 mg twice daily based on the antibiotic susceptibility tests and was discharged from hospital. A repeat ultrasound examination 2 weeks after initiation of treatment showed complete resolution of the abscess. He was given co-trimoxazole for a total duration of 4 weeks. He has received regular follow-up and is doing well at 12 months. Our patient had P. vivax malaria with a rare complication of splenic abscess, which is previously unreported. There have been case reports of P. falciparum infection complicated with splenic abscess occurring as a result of suppressed humoral and cellular immunity.3,4 Other risk factors for splenic abscess formation are neoplasia, immunodeficiency, trauma, metastatic infection, splenic infarct or diabetes.5 Our patient was previously healthy and had no evidence of immunodeficiency. The clinical features of splenic abscess are nonspecific, such as fever with chills, left upper quadrant abdominal pain, diffuse abdominal pain, shortness of breath, splenomegaly, left upper quadrant tenderness and diffuse abdominal tenderness. Our patient had fever with chills and hepatosplenomegaly with no abdominal pain. Ultrasonography is the imaging of choice for splenic abscess.5 The commonest organisms causing splenic abscesses are streptococci and Klebsiella as reported by Lee et al5 and by Rattan et al. Emergency splenectomy or percutaneous drainage with appropriate antibiotics has been done in the two case reports of P. falciparum infection complicated by splenic abscess.2,3 Conservative procedures, such as computed tomography or ultrasonography guided percutaneous drainage procedures, have been in vogue of late with successful outcome in 67–100% as it prevents post splenectomy sepsis as well as retaining the spleen in children.5 Our patient was treated with ultrasound guided percutaneous drainage followed by antibiotic therapy for a period of 6 weeks. His repeated imaging studies showed complete resolution of abscess. Jolly Chandran, MD Indira Agarwal, MD Winsley Rose, MD Department of Pediatrics Christian Medical College Vellore, Tamil Nadu, India