Introduction

Splenic abscesses, like abscesses elsewhere, are localized collections of necrotic inflammatory

tissue caused by bacteria, parasites or fungi.
They uncommonly affect the spleen due to its efficient reticuloendothelial system phagocytic
activity and, consequently, are more likely seen in immunosuppressed patients.
Splenic abscesses are uncommon, and their incidence in various autopsy series is estimated at
~0.4% (range 0.14-0.7%). The frequency may be rising due to an increase in the use of
immunosuppressive agents and prevalence of immunosuppressive states, higher survival
of leukemic patients, and a high incidence of intravenous drug use.

Case Report
A 45-year-old man who works as a clerk presented to the outpatient clinic with persistent pain in
the left upper quadrant area of the abdomen of 1 month duration.
The pain was said to have started about 1 month previously, with periods of temporary
improvement and relapse.
The pain was not affected by food intake or sleep. There was no other symptoms, such as
vomiting, nausea or fever. Moreover, the patient was not treated for any other disease at the time
(including recent infection or operation), nor had he ever been admitted to the hospital in the
past.
Clinical examination revealed localized sensitivity in the area of the spleen, with no other
significant findings.
The full blood count done revealed mild leukocytosis. Blood and urine cultures failed to reveal
any pathogens.
Imaging included chest and abdominal X-ray, followed by a CT scan of the upper abdomen. The
latter detected a large abscess of the spleen, of an average size of 8 cm × 4 cm.

Aspiration of the abscess was performed under CT guidance and the material obtained was
cultured, which led to the development of several colonies identified as Streptococcus spp. No
other pathogen of any kind was detected in the cultures.
Owing to the abscess being symptomatic and of considerable size, the decision to perform
splenectomy was made. The operation was completed successfully. Follow-up 1 year later has
revealed a completely asymptomatic postoperative period.
Radiologic differential diagnoses
The differential diagnoses that were considered included splenic cyst, splenic tuberculosis,
splenic lymphoma and splenic hamartoma.
Splenic epithelial cysts, also known as splenic epidermoid cysts or primary splenic cysts, are
unilocular fluid lesions with thin and smooth walls and no enhancement. They represent ~20% of
cysts found in the spleen, and are usually an innocuous incidental imaging finding. This
differential was considered because although the other properties were absent, the lesion seen
was also unilocular and located in the spleen.
Splenic tuberculosis refers to tuberculosis affecting the spleen. It generally occurs due to
hematogenous spread from the primary site of infection, commonly from pulmonary
tuberculosis. It was considered a differential because of the prevalence of tuberculosis in this
area. However, other features suggestive of tuberculosis were absent in this patient.

Splenic lymphoma is a malignancy arising from lymphocytes or lymphoblasts, and which affects
the spleen. Lymphoma can be restricted to the lymphatic system or can arise as extranodal
disease. It was however ruled out because of the short duration of the illness and the absence of
any aggressiveness, among other things, which might suggest that it’s a lymphoma.
Splenic hamartomas are very rare lesions commonly found incidentally on imaging. They are
most often solitary but may be present as multiple nodules in patients with tuberous
sclerosis or Wiskott-Aldrich syndrome. Hamartomas are solitary or multiple, round, well-
circumscribed, unencapsulated bulging nodules compressing the adjacent normal splenic
parenchyma and compounded by a mixture of normal splenic structures such as white and red
pulp. Focal fibrosis and cystic areas can be seen. This was however ruled out because of the
duration and time of presentation, and the imaging finding that was more consistent with an
abscess.

Discussion
Abscess of the spleen is a rather rare clinical entity. About 600 cases have been
described so far in the international literature.
Most of these refer to patients with recognized risk factors. These include the
synchronous presence of conditions that compromise the immune system, such as
endocarditis, diabetes mellitus, congenital or acquired immunodeficiency and the
administration of immunosuppressive medication (e.g. post-transplantation or as
part of the treatment of connective tissue disorders). Trauma is an additional
predisposing factor for splenic abscesses.
Instances of splenic abscesses are relatively increased among intravenous drug
addicts. On the other hand, splenic abscesses are most uncommon in the general
population. From an epidemiological point of view, they are more frequently
detected in middle-aged and older individuals, with no obvious preference for
either sex.
The clinical manifestations of splenic abscesses usually include abdominal pain,
exclusively located or, at least, more intensely described in the left upper quadrant
area. Fever, nausea, vomiting and anorexia may be also present in various
combinations.
Laboratory findings are consistent with the acute phase of infection, but their exact
nature is determined by the pathogen isolated from the abscess. The most common
pathogens detected include Staphylococcus and Streptococcus.
Imaging by common abdominal X-ray or ultrasound may be suggestive, but the
lesion is usually revealed via computed tomography (CT). Due to the seriousness
of the potential implications, including a threat to life itself, the most usual
treatment currently applied is splenectomy, which is followed by rapid clinical
improvement.
The modality-based radiologic features commonly seen includes:

Plain radiograph

A plain abdominal radiograph is insensitive in the evaluation of splenic abscesses. Indirect signs
include gas within the abscess, and a reactive left-sided pleural effusion.

Ultrasound

Splenic abscesses are typically poorly-demarcated with a variable appearance, ranging from
predominantly hypoechoic with some internal echoes to hyperechoic. They may contain septa of
varying thickness. The presence of gas bubbles may also be seen with reverberation artefact,
although the majority of splenic abscesses do not contain gas.

Ultrasound may also be used to guide abscess aspiration.

CT

Abscesses are normally seen as centrally low-density lesions (20-40 HU). Minimal peripheral
contrast enhancement may be present once a capsule has developed. Ascites and adjacent pleural
effusion can be seen.
MRI

May show solitary, multiple, or multilocular intrasplenic lesions. MR imaging characteristics can
vary dependent on the size and infectious agent. 

Usually, the abscesses are of fluid signal intensity.

 T1: low signal (T1 signal may increase if there is proteinaceous content)

 T2: high signal 
 T1 C+ (Gd)
o there can be minimal peripheral enhancement once a capsule develops
o larger lesions can also show peripheral and perilesional enhancement
Nuclear Medicine

The clinical context is vital in interpreting nuclear medicine images. 

In some cases, Tc-99m HMPAO leukocyte scans or Tc-99m HIG (human polyclonal

immunoglobulin) scans may show one or more intrasplenic defects.

Indium-111 leukocyte scans and Ga-67 scans may also show a photopenic abscess cavity.

Treatment

Traditional treatment for splenic abscess has been splenectomy and antibiotic therapy but image-
guided percutaneous aspiration and drainage can also be considered.

While many advocate image-guided drainage, several publications suggest that splenectomy has
a better outcome than percutaneous drainage or intravenous antibiotics alone.

Complications

A number of complications could arise from a splenic abscess and its treatment. These include
but not limited to pneumothorax, atelectasis, left-sided pleural effusion, hemorrhage in case of
splenic rupture, subphrenic abscess, fistulation and contiguous spread to surrounding structures,
post splenectomy thrombocytosis etc.

Conclusion
In conclusion, splenic abscess, though rare, is more common among immunocompromised
patients and is unrelenting. It is therefore essential for medical practitioners to have a high index
of suspicion in diagnosing the condition and instituting early investigative measures to confirm
the diagnosis and a definitive treatment given in order to avoid the myriads of complications that
could arise.

References
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