Summary: A 64-year-old diabetic man presented with a 10-day history of fever and upper-abdominal pain.
The patient had been treated with oral levofloxacin for a lower urinary tract
infection 2 weeks previously. The urine examination conducted at that time had
revealed abundant pus cells and frank glycosuria. At this subsequent presentation,
clinical examination revealed left upper-quadrant tenderness. Laboratory
investigations showed random venous blood glucose of 435 mg/dl, 60 pus cells/hpf
in urine with glycosuria and without ketonuria. Ultrasonography of the abdomen
showed a splenic cystic lesion with internal echoes. The exam also revealed a mild
prostate enlargement with post-void residual urine of 35 cc. CT scan of the
abdomen was performed for further evaluation.
Differential diagnoses: true cyst, hydatid cyst, cystic haemangioma, lymphangioma,
epidermoid cyst, and cystic metastasis.
A CT scan (Figure 1) revealed a hypodense, nonenhancing splenic lesion with a
well-defined, slightly irregular, minimally enhancing wall. The lesion measured
about 8.0 x 6.0 x 5.6 cm. Minimal stranding is seen in the mesenteric fat
between the spleen and the stomach, with minimal left pleural effusion.
Additional CT images showed secondary signs such as minimal left pleural effusion (Figure
2) and small, subsegmental atelectasis in the left lower lobe (Figure 3),
secondary to hypoventilation.
Urinary tract infections are more common among diabetic patients compared to the
general population. In addition to their impaired immune system, some patients
with longstanding diabetes have impaired urinary voiding. Age-related prostate
enlargement can compound this voiding dysfunction. The residual urine in the bladder
acts as a culture medium for bacteria.
Splenic abscess by itself is an unusual entity, with a reported frequency ranging from 0.05%
to 0.7%. 1 Splenic abscess as a complication of lower-urinary-tract
infection (cystitis) is extremely rare. It usually develops as a result of the haematogenous spread of bacteria from an
infective focus located elsewhere in the body. Infective endocarditis, typhoid,
paratyphoid, urinary tract infection, pneumonias, osteomyelitis, otitis,
mastoiditis, and pelvic infections can all lead to splenic abscess, albeit
rarely.2 Diabetics, alcoholics, and immunocompromised patients are
more susceptible to splenic abscesses.3 A variety of microbes,
including gram-positive cocci, gram-negative bacilli, anaerobes, and candida,
have all been reported as causative agents.
Ultrasound is an excellent modality for accurately diagnosing cystic lesions of the spleen.
A splenic abscess usually appears as an anechoic (cystic) lesion with an
irregular wall and internal echoes. Other differential diagnoses of splenic
cystic lesions include true cyst, hydatid cyst, haemangioma, lymphangioma and
cystic metastasis.4 CT is the diagnostic modality of choice for evaluating
splenic cystic lesions. A splenic abscess may show minimal wall enhancement f a
capsule has developed. According to a Taiwanese study, 59% of splenic abscess cases
had at least one of the following findings on CT: abnormal gas content,
progressive lesion enlargement, subcapsular lesion extension, and extracapsular
fluid collection.5 However, as seen in this case, the secondary
imaging features of inflammation, such as perilesional mesenteric fat stranding
and ipsilateral reactionary pleural effusion, also help in making the
Hydatid cyst is an important differential diagnosis for splenic abscess. On CT images,
these cysts appear homogeneous, with attenuation equal to water. They may show
membranes (water lily sign), daughter cysts, peripheral-wall calcification, and
concurrent hepatic cysts—all features that help in differentiating hydatid cyst
from other cystic lesions.6 In addition to imaging, peripheral blood
eosinophilia is an important finding associated with hydatid cyst.
Percutaneous drainage under image guidance is now accepted as a less-invasive and effective
method of treatment for splenic abscess.7,8 It helps prevent
splenectomy and that procedure’s associated complications. The reported success
rate of percutaneous drainage ranges from 67% to 100%.7,8 Surgery is
reserved for cases that are not amenable to percutaneous drainage; these
include abscesses that are not easily accessible and/or multiloculated abscesses
that are unlikely to drain completely by percutaneous aspiration. Imaging
guidance, however, makes access to splenic abscesses simpler and safer.
Patients with diabetes are more prone to infections than are the general population.
Rarely, local infection can lead to unusual distant complications that may be
diagnostically and therapeutically challenging. Splenic abscess is such an
unusual complication of cystitis. CT is an excellent modality for accurate
diagnosis and guided aspiration of splenic abscess.
- Chang KC, Chuah SK, Changchien CS, et al.
Clinical characteristics and prognostic factors of splenic abscess: A review of
67 cases in a single medical center of Taiwan. World J Gastroenterol. 2006;12:460-464.
- Fotiadis C, Lavranos G, Patapis P, et al.
Abscesses of the spleen: Report of three cases. World J Gastroenterol. 2008;14:3088-3091.
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M, Mergo PJ, Ros LH, Torres GM, Ros PR. Cystic masses of the spleen: Radiologic-pathologic
KK, Lee TY, Wan YL, et al. Splenic abscess: Diagnosis and management. Hepatogastroenerology.2002;49:567-571.
M, Mergo PJ, Ros LH, et al. Cystic masses of the spleen: Radiologic-pathologic
G, Brunetti E, Gulizia R, et al. Management of splenic abscess: Report on 16
cases from a single center. Int J Infect Dis. 2009;13:524-530.
SR, Rajiv C, Pitamber S, et al. Management of splenic abscess in children by
percutaneous drainage. J Pediatr Surg.