Unusual case of multiple hepatosplenic abscesses caused by Staphylococcus aureus

Abstract

Background: Combined liver and splenic abscesses are very rare in people without underlying diseases or immune-deficiencies, and can be fatal. Clinical presentation may not be straight-forward. Case description: A 19 year old male was admitted to the Emergency Unit with 2 days fever, left-sided loin pain and vomiting. After examination, the patient was admitted to a medical ward with a presumptive diagnosis of urinary tract infection. Physical examination revealed signs of an acute abdomen and the patient was referred to a surgeon. On further history, a fall from a tree with blunt trauma to the abdomen was elicited. Splenic rupture was suspected and confirmed by ultrasound scan abdomen. Laparotomy was performed. The spleen was lacerated in several places with peri-splenic haematoma formation. Splenectomy was performed. Multiple small abscess-like lesions were observed on the liver and biopsies were taken and sent for microbiology and histopathology. Meropenem was started post-operatively on a presumptive diagnosis of melioidosis and clindamycin. Primary culture of liver tissue showed no growth after 24 hour incubation. A pure growth of Staphylococcus aureus sensitive to cloxacillin was obtained on enrichment of the tissues in Blood Heart Infusion broth. Treatment was changed to intravenous cloxacillin and ciprofloxacin and the patient kept under strict observation. The histopathology report revealed colonies of Gram positive cocci in the biopsies taken from the liver and spleen. Size of the lesions in the liver initially increased up to 1 cm and then gradually reduced. Inflammatory markers (CRP, FBC), too, initially increased, then gradually normalized. Serology by the indirect hemagglutination assay for Burkholderia pseudomallei antibody was negative. Patient was fever free by the 5th day. Computed tomography chest, abdomen and head were done to exclude abscesses in other organs and 2D-echocardiogram to exclude endocarditis. The patient was treated with IV cloxacillin for 6weeks and discharged on oral cloxacillin for 3 weeks after giving vaccines as indicated in asplenism. Discussion: Atypical presentation of hepatosplenic abscesses may lead to misdiagnosis. Vigilance and open-mindedness for unusual manifestation of hepatosplenic abscesses on the differential diagnosis, even in patients without any risk factors, may improve the prognosis. Conclusion: Awareness and vigillance for atypical infections is life saving.