Pediatrics and Neonatology (2013) 54, 409e412
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CASE REPORT
Multiple Large Splenic Abscesses Managed with Computed Tomography-guided Percutaneous Catheter Drainage in Children Jung Sook Yeom a, Ji Sook Park a, Ji-Hyun Seo a,*, Eun Sil Park a, Jae-Young Lim a, Chan Hoo Park a, Hyang Ok Woo a, Jung Je Park b, Jae Min Cho c, Hee-Shang Youn a a
Department of Pediatrics, Gyeongsang National University, School of Medicine, Gyeongsang Institute of Health Science, Jinju, South Korea b Department of Otorhinolaryngology, Gyeongsang National University, School of Medicine, Gyeongsang Institute of Health Science, Jinju, South Korea c Department of Diagnostic Radiology, Gyeongsang National University, School of Medicine, Jinju, South Korea Received Aug 1, 2011; received in revised form Feb 15, 2012; accepted May 23, 2012
Key Words percutaneous drainage; splenic abscess
Splenic abscess is a rare finding in children. Splenectomy combined with broad-spectrum antibiotics has been the treatment of choice for multiple splenic abscesses. Herein, we report the case of a 14-year-old girl with multiple large splenic abscesses that were successfully managed after two image-guided percutaneous drainage procedures and administration of intravenous antibiotics. Initially, an abscess located at the periphery in the lower pole of the spleen was aspirated under ultrasound guidance. Finally, another abscess located near the hilum of the spleen was drained under computed tomography guidance. To the best of our knowledge, this is the first report of multiple large splenic abscesses treated with computed tomographyguided percutaneous drainage. Copyright ª 2013, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
* Corresponding author. Department of Pediatrics, Gyeongsang National University Medical School, 90 Chilam-dong, Jinju 660-702, South Korea. E-mail address:
[email protected] (J.-H. Seo).
1. Introduction Splenic abscess is a rare but potentially life-threatening condition in children. The most common organisms
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obtained from the abscess tissue culture are aerobic microbes, particularly staphylococci, streptococci, Salmonella, and Escherichia coli.1 Normally, antibiotics are effective in clearing bacteremia; however, the organisms in the abscess were not eradicated, as evidenced by the traces still found in the culture.2 Therefore, the treatment strategy for splenic abscess has been splenectomy combined with a broad-spectrum antibiotic therapy.1,3 However, recent advances in radiology have affected the diagnosis and management of splenic abscess, and
Figure 2 Follow-up abdominal computed tomography scan showing the inserted percutaneous drainage catheter in the abscess of the spleen; the sizes of the abscesses are decreased compared with those seen in the previous computed tomography scan.
percutaneous drainage of splenic abscess is considered a reliable technique, with a high therapeutic success rate and low costs compared with surgery.4e6 The most straightforward imaging guidance modality for abscess drainage in children is ultrasonography (US), which has the advantages of providing real-time guidance and no radiation hazard. As compared with US, computed tomography (CT) may offer more precise localization of the abscess, better delineation of adjacent vital structures, and visualization of the needle or catheter tip, 4,5 which is important when the abscess is adjacent to major vessels or the bowel.7 In this article, we report the case of multiple splenic abscesses in a 14-year-old girl, managed with image-guided percutaneous drainage and antibiotics. An abscess located adjacent to the splenic hilum was successfully drained under CT guidance.
2. Case Report Figure 1 Contrast-enhanced computed tomography images of the abdomen revealing multiple splenic abscesses and a perisplenic abscess. (A) A large amount of perisplenic abscess enveloped posterior to the medial portion of the upper pole of the spleen and (B,C) finally communicated with the abscess located adjacent to the hilum of the spleen (3.5 cm; thin arrow in B and C). Ring enhancement was found in the abscess near the posterior chest wall (4.0 cm; thick arrow in C).
A 14-year-old girl presented with high-grade fever, chills, diffuse abdominal pain, and bilious vomiting. She was previously healthy and had no history of trauma, jaundice, or other associated illnesses. On the day of admission, the following vital signs were recorded: body weight, 40.9 kg; height, 158.8 cm; blood pressure, 80/60 mmHg; pulse rate, 88/minute; respiration
CT guided drainage in multiple splenic abscesses rate, 20/minute; and body temperature, 38.6 C. An abdominal examination revealed tenderness over the epigastric and left lower quadrants. The patient’s initial laboratory findings were as follows: white blood cell count, 3.29 109/L; hemoglobin, 137 g/L; hematocrit, 40.0%; aspartate aminotransferase, 109 IU/L; alanine aminotransferase, 51 IU/L; total bilirubin, 27 mg/L; direct bilirubin, 22 mg/L; albumin, 34 g/L; blood urea nitrogen, 320 mg/L; creatinine, 15 mg/L; and C-reactive protein, 258.7 mg/L. The Widal test result was 1:160 for O agglutinins and 1:40 for H agglutinins. The results of routine urinalysis were normal. On Day 3 after admission, the CT image revealed multiple splenic abscesses, with the largest one measuring 4.0 cm, and a perisplenic abscess nearly enveloped posterior to the median portion of the upper pole of the spleen (Figure 1). The antibiotics were changed from cetotaxime to piperacillin/tazobactam and amikacin. However, high fever persisted, and then aspiration of the nearest abscess, the one on the posterior chest wall (thick arrow in Figure 1C), was performed under US guidance on Day 6 of admission. Cefotaxime-, amikasin-, and piperacillin/tazobactam-sensitive E. coli was cultured in the drained pus. Nevertheless, fever was still noted, and there was no change in the size of the abscesses that remained. On Day 9 of admission, CT-guided percutaneous catheter drainage of the abscess located adjacent to the splenic hilum (thin arrow in Figure 1B and C) was performed using local anesthesia and an 8F pigtail catheter (Huisman Percutaneous Drainage Set; Cook, Bjaeverskov, Denmark; Figure 2). The pigtail catheter was introduced to the posterior surface of the perisplenic abscess cavity of the upper pole of the spleen (Figure 1A), which provided space to go around the spleen inwardly without penetration of spleen. The catheter was then manipulated downwardly to reach the perihilar abscesses, which was possible due to communication between perisplenic abscess and perihilar abscess. No intervention-related complications were noted. The next day, the fever subsided and the sizes of the splenic abscesses were decreased. No other pathogen was found in the blood, urine, or bone marrow. On Day 24 of admission, the antibiotics were discontinued. On Day 26 of admission, the patient was discharged in good general condition.
3. Discussion Since the first report of successful treatment with US-guided catheter drainage of a solitary splenic abscess in a pediatric patient in the mid-1980s,8 several cases of similar results have been reported.5,7,9,10 Some authors have insisted that US- or CT-guided drainage is suitable for patients with critical illnesses where surgery is contraindicated or in young patients in whom splenic preservation is desirable; moreover, the procedure should be limited to unilocular abscesses, with thin fluid content, a discrete wall, and no septations.1 The number of splenic abscesses is another important factor influencing the decision of which therapeutic strategies to use. If there are more than two collections, surgical treatment is preferred.4 Actually, most reported cases of pediatric splenic abscess managed with percutaneous drainage were single abscesses. However,
411 pediatric cases of multiple splenic abscesses managed with percutaneous aspiration or drainage were reported recently. Choudhury et al reported successful management of pediatric cases of multiple splenic abscesses by conservative management.9,10 They reported that US-guided percutaneous needle aspiration was performed in 10 cases (56%; all >3 cm), four of which involved multiple abscesses.9 They documented that the larger collection was drained among the multiple abscesses and the smaller collections responded to antibiotics treatment.9 They suggested that an isolated splenic abscess in children responds favorably to conservative treatment with intravenous broad-spectrum antibiotics and percutaneous drainage without the need for splenectomy, even in cases of multiple abscesses.9 Our experience of multiple splenic abscesses in this case was consistent with that of Choudhury et al. However, our case was distinctive compared with the multiple splenic abscesses described by Choudhury et al. Our patient had two large splenic abscesses (>3 cm), one located at the periphery in the lower pole of the spleen and the other located in the ventral portion of the spleen (near the hilum of the spleen). The removal of a significant amount of aspirate from the abscess in the lower pole under US guidance did not yield sufficient clinical responses, despite the administration of suitable antibiotics. The surgical approach may be regarded as the next solution because of the presence of another large abscess located adjacent to vessels, near the splenic hilum. Generally, percutaneous drainage is most likely to succeed when it is located at the periphery or at the middle or lower pole of the spleen.4 However, CT-guided percutaneous drainage was performed in this case for the following reasons: (1) CT guidance could offer precise localization, which is important when the abscess is adjacent to major vessels or the bowel4; and (2) there had been reports of successful and safe results using CT guidance, even in the case of poorly accessible splenic abscesses.4,11 Above all, we wanted to preserve the spleen because it is essential for proper immunologic function in children. Conclusively, the patient was treated effectively and safely by CT-guided percutaneous drainage and the spleen was preserved. In this case, the perisplenic abscess located at the posterior surface of the spleen provided an access route and a space to avoid spleen parenchymal penetration, which is one of the most important factors in minimizing complications. Together with abscess drainage, medical therapy with antibiotics is also important in the management of splenic abscess. The duration of medical therapy with intravenous antibiotics varies according to the abscess size and pathogen, ranging from 2 weeks to 4 weeks.10 Some authors recommend that aggressive management should be encouraged when splenic abscess is caused by Gramnegative bacilli.12 In this case, E. coli was isolated, and the patient was managed with aggressive intervention combined with 4 weeks of antibiotic therapy. To the best of our best knowledge, this is the first report of multiple splenic abscesses in a child treated by CT-guided percutaneous drainage. This was a successful attempt at percutaneous drainage of an abscess located near the splenic hilum. CT-guided percutaneous drainage should thus be considered in complex cases of splenic abscess.
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