Baylor University Medical Center Proceedings April 2017 - 173

Systemic infection and splenic abscess
Aaron R. Belknap, MD, and Joseph Guileyardo, MD

Splenic abscess is a rare complication of systemic infection, sometimes
associated with infective endocarditis. Due to its rarity and nonspecific
symptoms, diagnosis is difficult. Antibiotic therapy alone is usually unsuccessful, and definitive treatment requires splenectomy, although percutaneous ultrasound-guided drainage has been successful in some patients.
Abdominal computed tomography scans and ultrasound evaluation are
usually diagnostic. We present two patients with treatment-resistant
sepsis who were found at autopsy to have splenic abscess.

plenic abscess is a rare complication of systemic infection, but when present may be associated with bacterial
endocarditis (1). Considering the spleen's function of ﬁltering blood, splenic abscess is surprisingly uncommon.
In 564 patients with infective endocarditis, only 5% developed
a splenic abscess (2). Due to its nonspeciﬁc signs and symptoms,
the diagnosis is easily missed or delayed. Successful treatment
usually requires surgical resection of the infected spleen (3).
Computed tomography scans and ultrasound usually identify
the splenic lesion. We present two patients with treatmentresistant systemic infections who were found at autopsy to have
splenic abscesses.
CASE REPORTS
Case 1
A 57-year-old woman with chronic lower back pain presented to an outside hospital with a 1-month history of nausea,
vomiting, and fatigue. Three to four days prior to admission, she
had been bitten by her dog. The outside hospital diagnosed septic shock, and she was transferred to Baylor University Medical
Center at Dallas. Blood cultures were positive for Streptococcus
anginosus.
She was given broad-spectrum antibiotics, vancomycin, meropenem, clindamycin, and eventually continuous penicillin
infusions. However, she continued to deteriorate with intermittent fevers, distal ischemic necrosis of the hands and feet, and
large cutaneous bullae. Clinically, she developed disseminated
intravascular coagulopathy and suspected toxic shock. Chest
x-ray suggested an acute respiratory distress syndrome. Despite
therapy, she did not improve, was transitioned to comfort care,
and died.
Proc (Bayl Univ Med Cent) 2017;30(2):173-174

Autopsy found a puncture wound consistent with a dog bite
on the left index ﬁnger. Ischemic necrosis of the distal extremities and acute lung injury were also conﬁrmed. An unexpected
ﬁnding was a subcapsular splenic abscess measuring 3.5 cm
in greatest dimension with associated organizing splenic vein
thrombosis. She died from multisystem organ failure due to a
systemic inﬂammatory response syndrome associated with septic
shock, likely due to Streptococcus anginosus.
Case 2
A 52-year-old man with severe obesity, sleep apnea, and
atrial ﬁbrillation presented to an outside hospital for atrial ablation therapy. Following this procedure, he developed a bloody
pericardial eﬀusion, pericarditis, and multiorganism bacteremia
including Gemella sp., Prevotella sp., Fusobacterium nucleatum,
anaerobic gram-positive cocci, and anaerobic gram-negative
coccobacilli. Culture of the pericardial eﬀusion was positive
for Propionibacterium acnes. Cranial imaging demonstrated
multifocal acute and subacute hemorrhagic infarcts in addition to multiple cerebral abscesses. Following deterioration of
his condition, the patient was transferred to Baylor University
Medical Center at Dallas for a higher level of care.
Upon arrival, intensive antibiotic therapy including central
nervous system doses of vancomycin, ceftriaxone, metronidazole, and ceftazidime were given, but the source of the continuing bacteremia could not be identiﬁed, and the patient remained
febrile. A few days following transfer, the patient suﬀered myocardial infarction with troponin levels peaking >200 ng/mL,
but due to the cerebral hemorrhage, he was not a candidate
for anticoagulation. He was transitioned to comfort measures
and died.
An autopsy confirmed multifocal organizing cerebral
hemorrhages and abscesses, pericarditis, and an acute myocardial infarction. The autopsy also demonstrated multifocal splenic
abscesses, with the largest measuring 6.0 cm in greatest dimension. The patient died from complications of morbid obesity
From the Department of Pathology, Baylor University Medical Center at Dallas,
Texas.
Corresponding author: Aaron R. Belknap, MD, Department of Pathology, Baylor
University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246
(e-mail: aaron.belknap@baylorhealth.edu).
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