Splenic Abscess due to Clostridium perfringens

Abstract

To the Editor: Splenic abscess is an uncommon clinical entity with an incidence of 0.14% to 0.7%.1 The common causative organisms are aerobic. Anaerobic organisms such as clostridial species are rarely implicated. We present a case of an elderly woman with splenic abscess that grew Clostridium perfringens. CASE REPORT A 64-year-old woman presented with a 2-week history of left upper quadrant abdominal pain associated with fever, nausea, vomiting, and diarrhea. She denied any history of recent antibiotic use, travel, or sick contacts. Patient had a colonoscopy 4 years before presentation which revealed a polypoid leiomyoma in the sigmoid colon; a follow-up colonoscopy a year later revealed hyperplastic polyps in the transverse colon that were removed. History was otherwise noncontributory. On examination, patient was in mild distress because of abdominal pain. Vital signs showed a temperature of 36.4°C and a pulse rate of 110/min. Abdominal examination was significant for left upper quadrant tenderness and splenomegaly. The rest of the physical examination finding was unremarkable. Laboratory data showed marked leukocytosis (white blood cell count of 21.8 × 103/mm3 with 82% neutrophils and 7% bands) and C-reactive protein of 17.5 mg/dL. The rest of the laboratory results were within normal limits. Chest radiograph revealed an elevated left hemidiaphragm. Computed tomography (CT) of the abdomen with contrast revealed an air-fluid level along the posterior part of the spleen consistent with an abscess (Fig. 1). The patient was empirically started on intravenous piperacillin-tazobactam and had a CT-guided percutaneous catheter drainage of the abscess. Abscess drain cultures were positive for C. perfringens, and the antibiotics were changed to ampicillin-sulbactam. Stool was negative for Clostridium difficile toxin. Blood cultures were negative. An echocardiogram of the heart revealed no valvular vegetations. Malignancy workup was negative. Colonoscopy revealed adenomatous polyps in the transverse colon, and she underwent polypectomy. The patient was discharged on intravenous clindamycin for dosage convenience. Her condition improved, and serial abdominal CT scans done over the next few weeks revealed a decrease in the abscess size. The drain was removed after she completed a 6-week course of antibiotics.FIGURE 1: Computed tomography of the abdomen with contrast showing air-fluid level in the spleen.She presented with similar complaints 4 weeks later. A repeat CT of the abdomen revealed recurrence of the splenic abscess. She then underwent splenectomy; dense adhesions were noted along the splenocolic ligament on exploratory laparotomy. She was discharged uneventfully on postoperative day 8. DISCUSSION Splenic abscess is rare with a subtle clinical presentation and requires a high index of suspicion. The most common clinical features are fever, left upper quadrant pain, and splenomegaly.2 Diagnosis is mainly radiological. Ultrasonography is a good noninvasive technique, but CT has the highest sensitivity and specificity.2 Aerobic organisms are the most common organisms isolated and include staphylococcus and streptococcus species, salmonella, and Escherichia coli1-3; anaerobes account for 10% only. Most of the cases reported in the past due to clostridial species had predisposing factors such as malignancy, colitis, hematologic diseases, diabetes, or trauma.4-7 A review of literature revealed 2 reported cases of splenic abscess due to C. perfringens6,8; one had trauma as a predisposing cause, and the other one speculated diabetic microvascular injury as a possible factor. The source of C. perfringens in our patient remained obscure except for the history of diarrhea suggesting colitis and repeated polypectomies with breach in colonic mucosa acting as a possible portal of entry.