Psoas abscess in hemodialysis patients

Background  

The insidious onset and occult characteristic of psoas abscess can cause diagnostic delays, resulting in high mortality and morbidity rates. Here, we investigated the characteristics of psoas abscess in hemodialysis patients.     

脾脓肿

目的　介绍脾脓肿的病因 ,发病机理 ,临床表现及诊治方法。方法　根据作者收治的 9例脾脓肿的临床资料 ,结合文献复习。结果　脾脓肿可分为尸检型和临床型。尸检发现率为 0 4%～0 7%。临床型以单发巨大脾脓肿多见。脾脓肿主要为血源性感染所致。早期临床表现无特殊性。血培养阳性率为 1 5 %～ 70 % ,影像学检查对诊断有帮助。本病误诊率高达 2 2 2 %～ 50 %。脾脓肿手术治疗效果好。结论　脾脓肿临床少见 ,术前诊断率低 ,易误诊漏诊。一经确诊 ,应及时手术治疗。     

Splenic abscess

We present 7 cases of splenic abscess collected in our hospital from 1980 to 1988 as well as a review of 227 cases of the world literature. The signs and symptoms are nonspecific in all of them, fever being the most constant. Computed tomography scan followed by sonography were demonstrated to be the best methods of diagnosis. The treatment carried out on all of our patients was splenectomy followed by antibiotic coverage. Two of them died 15 days after the operation due to persistence of the septic state. In our review of the literature, we observe a rise in the population at risk for splenic abscess due to an increase in the use of immunosuppressive agents, to the higher survival of leukemic patients, and to the great incidence of drug abuse among others. Nevertheless, the advances in the use of sonography and computed tomography scan have made possible a more accurate diagnosis, therefore making possible an earlier treatment and a better prognosis. We believe that the treatment of choice is splenectomy with conservative treatment used only in specific cases where surgery represents a high risk for the patient.

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Resumen Presentamos 7 casos de absceso esplénico recolectados en nuestro hospital entre 1980 y 1988 y la revisión de 227 casos de la literatura mundial. Los signos y síntomas aparecieron como no específicos, siendo la fiebre el más constante. La tomografía computadorizada, seguida de la sonografía, demostraron ser los mejores métodos de diagnóstico. El tratamiento empleado en la totalidad de nuestros pacientes fue la esplenectomía seguida de cubrimiento antibiótico. Dos pacientes murieron después de la operación debido a persistencia del estado séptico. En nuestra revisión de la literatura observamos un incremento de la población en riesgo de desarrollar absceso esplénico por el aumento en el uso de agentes inmunosupresores, por la mayor tasa de sobrevida de pacientes con leucemia y por la alta incidencia de drogadicción. Sin embargo, los avances en el uso de la sonografía y de la tomografía computadorizada han hecho posible un diagnóstico más certero, y, por lo tanto, un tratamiento más temprano con mejor pronóstico. Creemos que el tratamiento de elección es la esplenectomía y que el tratamiento conservador sólo debe ser usado en casos específicos en los cuales la cirugía represente un elevado riesgo para el paciente.

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Résumé Nous présentons 7 cas d'abscès splénique colligés dans notre hôpital de 1980 à 1988 et la revue de 227 cas de la littérature mondiale. Les signes et symptômes ne sont jamais spécifiques, la fièvre étant le plus constant. La tomodensitométrie et la sonographie, dans cet ordre, se sont avérées les meilleures méthodes de diagnostic. Le traitement appliqué à tous nos patients a été la splénectomie suivie d'une couverture antibiotique. Deux d'entre eux sont morts 15 jours après l'opération à cause de la persistance de l'état septique. Dans la revue de la littérature, nous observons une hausse de la population à risque d'abscès splénique à cause de l'augmentation de l'emploi d'agents immunodépresseurs, du taux de survie plus grand des patients leucémiques et du rôle important des excès de drogue chez les autres. Néanmoins, les progrès de la sonographie et de la tomodensitométrie ont rendu possible un diagnostic plus sûr, amenant de ce fait à un traitement précoce et un pronostic meilleur. Nous pensons que le traitement de choix est la splénectomie. Le traitement conservateur doit être réservé uniquement aux cas où la chirurgie présente de gros risques pour le patient.

     

Splenic abscess

Splenic abscess is an unusual disease and may be present either as a localized area of infection in the spleen or as a part of generalized sepsis. There are no specific clinical findings for a splenic abscess; the symptoms and signs of sepsis should arouse a suspicion of splenic abscess. Computerized axial tomography (CAT) scan probably offers the most direct way of evaluating the spleen and making an early diagnosis. Although gram-positive cocci are most frequently reported in splenic abscesses, there is enough variation of organisms that specific combination of antibiotics cannot be recommended. Antibiotic selection should be based on positive blood cultures and intraoperative cultures. The preferred treatment is splenectomy, although occasionally external drainage may be required. A successful outcome is dependent on an early diagnosis and prompt treatment by splenectomy. When splenic abscess is part of an overall septic process, the prognosis is generally very poor.

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Resumen bsceso esplénico es una entidad rara y puede estar presente bien como un área localizada de infección en el bazo o como parte de una sepsis generalizada. No existen manifestaciones clínicas específicas en el absceso esplénico; los síntomas y signos de sepsis deben provocar la sospecha de un absceso esplénico. El examen con el escáner (TAC) probablemente provee la manera más directa de evaluar el bazo y de lograr un diagnóstico temprano. Aunque los cocos Gram positivos son informados con máxima frecuencia en los abscesos esplénicos, existe suficiente variedad de organismos en tal forma que no es posible recomendar una combination específica de antibióticos. La selection del antibiótico debe fundamentarse en hemocultivos positivos y en el resultado de los cultivos intraoperatorios. El tratamiento de electión es la esplenectomía, aunque ocasionalmente el drenaje externo puede ser requerido. El resultado exitoso del manejo depende del diagnóstico precoz y de pronto tratamiento mediante esplenectomía. Cuando el absceso esplénico hace parte de un proceso séptico general, el pronóstico generalmente es muy pobre.

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Résumé Les abcès de la rate représentent une affection rare; ils peuvent être isolés ou accompagnés d'une infection générale. L'abcès de la rate ne présente pas de symptômes ou de signes particuliers. On doit simplement l'envisager en présence de toute infection dont l'étiologie n'est pas reconnue. La tomodensitométrie représente la meilleure méthode d'exploration de la rate. Elle permet un diagnostic précoce. Bien que les cocci gram + soit le plus souvent à l'origine des abcès spléniques, le grand nombre de bactéries en cause ne permet pas l'emploi d'une combinaison d'antibiotiques spécifiques. L'antibiothérapie doit être sélective en se basant sur les germes découverts dans le sang ou au niveau de l'abcès.Le meilleur traitement est la splénectomie bien que parfois on doive se contenter d'un drainage externe. L'évolution de l'affection dépend de la précocité du diagnostic et de la promptitude de la splénectomie. Lorsque l'abcès splénique est constaté au cours d'une infection généralée, le pronostic est généralement très grave.

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Supported in part by the Veterans Administration.     

Splenic abscess

Abscess of the spleen is a rare entity. It may develop after generalized infection, hematologic disorders and trauma. The authors report the case of a 7-year-old boy who presented with a 2-month history of spiking fever, anorexia, fatigue and weight loss. He had left subcostal tenderness and a palpable spleen. He had a history of trauma to the left flank 5 months before admission but a splenic scan obtained at that time appeared normal. A splenic abscess was diagnosed by gallium scanning, computerized tomography and ultrasonography. Although splenectomy has been advocated as the treatment of choice for splenic abscess, this patient was treated successfully with appropriate antibiotics and simple drainage, preserving the spleen. Cultures grew Staphylococcus aureus. Of all the diagnostic methods available, ultrasonography is the least invasive study that will make the diagnosis and is less expensive than some methods.     

Extra-renal abscess in chronic hemodialysis patients

AIM: Infectious disease represents one of the major causes of morbidity and mortality in hemodialysis patients. Extra-renal abscess constitutes a specific form of infection. The aim of this study was to evaluate and analyze the clinical characteristics of extra-renal abscess in chronic hemodialysis patients. METHODS: We retrospectively studied the extra-renal abscess among chronic hemodialysis patients in Chang Gung Memorial Hospital at Kaohsiung, Taiwan. The records of 2,168 chronic hemodialysis patients from October 1986 to January 2000, were studied. The clinical features were reviewed and analyzed. RESULTS: Sixteen patients who were enrolled during the study period developed extra-renal abscess. Ten of them were male. The mean age was 59.2 +/- 11.8 years old. More than half of the patients had diabetes (53.6%, 9/16). The locations of extra-renal abscess in these patients were liver (8/16), lung (5/16), spleen (1/16), perianal region (1/16), psoas muscle (1/16), and prostate (1/16). One patient had concurrent liver and spleen abscesses. All patients presented with fever and chills. Laboratory studies revealed leukocytosis and thrombocytopenia in 2/3 of the patients. The patients were associated with malnutrition status with lower serum albumin level (2.94 +/- 0.55 gm/dL) and lower nPCR (normalized protein catabolism rate; 0.84 +/- 0.11 gm/Kg/day) comparing to the other hemodialysis patients (albumin: 4.05 +/- 0.47 gm/dL; nPCR: 1.14 +/- 0.31gm/kg/day). There was no significant difference in kt/V between the patients with (1.28 +/- 0.34) or without abscess formation (1.47 +/- 0.36). The major causative pathogen was Klebsiella pnewnoniae. Parenteral antibiotic treatment is sufficient to treat most of the diseases, except 2 patients who needed surgical intervention. Twelve patients recovered after 2-3 weeks of treatment. Conclusions: The study indicated that extra-renal abscess is rare in chronic hemodialysis patients. The abscesses occurred mostly in liver. Diabetes mellitus and poor nutrition status were the important predisposing factors. Gram-negative bacilli, K. pneumoniae, were the major pathogen. Most of the patients responded to parenteral antibiotics and surgical draining.     

Splenic abscess.

A review of autopsy files and clinical case reports demonstrates two categories of splenic abscess. First, the abscesses discovered at postmortem usually are multiple, small manifestations of widespread, lethal infection in immunologically crippled hosts. A clinical diagnosis seldom is made. Second, the splenic abscesses encountered by the clinician are usually solitary, large, and challenge his diagnostic skills. Recognition is of vital importance, for therapy can be highly successful. Left untreated, the mortality rate is very high. The features, clinical management, and pathogenesis of splenic abscesses are discussed.     

Splenic abscess.

Isolated splenic abscess is an uncommon condition. Seven cases seen between 1980 and 1990 are reviewed. The clinical presentation is non-specific and diagnosis is usually delayed. Computerized tomography allowed for accurate diagnosis in all cases. Pseudomonas species as a causative organism is reported to be rare, but were present in three of the present cases. Antibiotic therapy alone is insufficient and splenectomy remains the treatment of choice.     

Splenic abscess after appendicitis

We report an appendicitis complicated by a splenic abscess in a patient with polycystic kidneys and multiple cystic lesions in the liver. Clinical decision making for operative intervention was made difficult by the extensive intra-abdominal abnormalities seen on computer tomography. Finally curation was achieved by splenectomy and appendectomy.     

Splenic abscess as complication of perinephric abscess

Retroperitoneal extension of perinephric abscess with fistulization to intra-abdominal and intrathoracic structures has been well documented in the literature. Intraperitoneal rupture is much less common, and exceptionally may not present as an acute abdominal condition. We describe herein 1 such case involving the spleen. Since the extent of the disease may not be apparent radiologically, and often is only ascertained at the time of surgery, we recommend an aggressive approach to renal calculi as the most effective means of preventing complicated perinephritis.     

Splenic abscess in an immunocompetent adult

Abscess of the spleen is, a rare clinical entity with about 600 cases documented to date, and an incidence of 0.2 to 0.7% in autopsy-based studies [1,2]. Because of its nonspecific clinical picture, splenic abscess constitutes a diagnostic challenge, but it should be suspected in febrile patients with left upper quadrant tenderness and leucocytosis. The diagnosis is based mainly on imaging studies, microbiological and/or histopathological evidence, or by response to antibiotic or antifungal treatment.A case of splenic abscess is reported here, which occurred in an immunocompetent male and was treated in a tertiary care institution in eastern India.     

Splenic abscess associated with endocarditis.

BACKGROUND. Refractory or recurrent sepsis in patients with endocarditis may be from splenic abscess. The purpose of this review is to assess this relationship. METHODS. Of 564 patients treated for documented endocarditis between 1970 and 1990, splenic abscesses developed in 27 patients. The mean age of the 18 men and nine women was 37 years. Etiologic factors included street drugs, dental abscess, and rheumatic fever. Symptoms included fever, myalgia, chills, and dyspnea; the prodrome averaged 2 weeks. Typical signs were heart murmur, left lower-lobe infiltrate, and leukocytosis. Splenomegaly was found in three patients. All patients had valve lesions, which involved the aortic valve alone in 10 patients, the mitral valve alone in eight patients, and multiple valves in nine patients. RESULTS. A splenic defect on computed axial tomographic scan was diagnosed correctly as an abscess in 10 patients, was indeterminant in three patients, and was incorrectly called an infarct in four patients. Thirteen patients died. All 10 patients treated without splenectomy died, including five patients who underwent valvular replacement. In contrast, only three of 17 patients treated by splenectomy with (11 patients) or without (six patients) valvular surgery died. CONCLUSIONS. Splenic abscess often accompanies endocarditis. The diagnosis is suspected by refractory fever and confirmed by abdominal computed axial tomography scan. Splenectomy is warranted before or after valvular surgery, depending on the patient's clinical response to antibiotics.     

Splenic abscess arising from acute cholecystitis

Splenic abscess is an uncommon surgical condition and is life-threatening if un-diagnosed earlier during the course of illness. Splenic abscess has been reported in association with hepatic abscess. This report describes a case of splenic abscess associated with cholecystitis. Since, the symptoms are generally non-specific, a high index of suspicion is necessary to diagnose splenic abscess in patients having acute or chronic cholecystitis. When such patients have fever and left upper quadrant pain, splenic abscess should be considered.     

Splenic abscess: therapeutic options]

Pyogenic splenic abscess is a rare condition that tends to occur in patients with underlying often infectious diseases. The sensitivity of ultrasonography and computerized tomography has improve early diagnosis and follow-up. In our hands, splenectomy remains the therapy of choice, but we report the resolution of two uncomplicated splenic abscesses with antibiotics alone.     

Splenic abscess with drainage and recovery

A study of the literature reveals that splenic abscess is not a condition encountered infrequently. With the use of all facilities for study the diagnosis should not present great difficulty. Splenotomy is most generally employed for surgical treatment of a splenic abscess but splenectomy is desirable in selected cases. We have reported a case of abscess of the spleen in which recovery followed operation.     

Splenic abscess. Apropos of 5 cases

Spleen abscesses are infrequent, and are encountered in 0.4 to 0.7%-of the autopsy series. They are diagnosed late and their prognosis is poor. The authors report about 5 cases of spleen abscesses observed at Dakar's University Surgical Clinic over a period of 30 years. The patients were young adults, including one case of sickle-cell anemia. In spite of numerous clinical signs in all cases, the abscess was diagnosed late. In three patients, ultrasound allowed establishing the diagnosis and initiating percutaneous treatment, with no success in two cases. The procedure had consisted in total splenectomy in all cases. One patient died 2 months after surgery, after the evacuation of a hematoma in the splenic compartment. The other 4 patients, seen 7, 4, 3 months and 15 years after total splenectomy, no longer presented with any symptom. The authors emphasize the rarity of spleen abscesses; the fact that the diagnosis is often established late, in spite of the progress made in non-invasive medical imaging, including CT and ultrasound; the physiopathology, etiology and treatment of the disease, the latter still being surgical.