Subphrenic abscess and rupture of the spleen

Abstract

A 68-year-old female patient was admitted with fever and lassitude. She had a long history of schizophrenia and lived in a psychiatric hospital. She was alert but appeared confused and acutely ill. She could not answer simple questions. Her blood pressure was 90/60 mm Hg, pulse 120/min and temperature 39·2°C. The chest was clear but left subcostal tenderness was noted. She had an elevated leukocyte count and C-reactive protein. Abdominal computed tomography (figure) showed a ruptured spleen (arrow) and free fluid below the left hemidiaphragm. We did a laparotomy and a splenectomy, and found a left-sided subphrenic collection of purulent fluid. Examination of the specimen showed a large infected haematoma, an abscess of the splenic parenchyma and fresh rupture of the capsule. Cultures grew Streptococcus viridans but echocardiographic studies failed to demonstrate any evidence of endocarditis. The patient made an uneventful recovery. Subphrenic abscess is a classical cause of fever of unknown origin. Eventually, it transpired that the patient had received aspirin and low-molecular weight heparin and fallen repeatedly. The psychiatric disease of our patient and her inability to give a history accounted for a difficult diagnosis in this case. A 68-year-old female patient was admitted with fever and lassitude. She had a long history of schizophrenia and lived in a psychiatric hospital. She was alert but appeared confused and acutely ill. She could not answer simple questions. Her blood pressure was 90/60 mm Hg, pulse 120/min and temperature 39·2°C. The chest was clear but left subcostal tenderness was noted. She had an elevated leukocyte count and C-reactive protein. Abdominal computed tomography (figure) showed a ruptured spleen (arrow) and free fluid below the left hemidiaphragm. We did a laparotomy and a splenectomy, and found a left-sided subphrenic collection of purulent fluid. Examination of the specimen showed a large infected haematoma, an abscess of the splenic parenchyma and fresh rupture of the capsule. Cultures grew Streptococcus viridans but echocardiographic studies failed to demonstrate any evidence of endocarditis. The patient made an uneventful recovery. Subphrenic abscess is a classical cause of fever of unknown origin. Eventually, it transpired that the patient had received aspirin and low-molecular weight heparin and fallen repeatedly. The psychiatric disease of our patient and her inability to give a history accounted for a difficult diagnosis in this case.