From the Guidelines
The patient is likely suffering from splenic abscess, a rare but serious complication that requires prompt diagnosis and treatment to prevent morbidity and mortality. The etiopathogenesis of splenic abscess involves bacteremic seeding of a bland infarction or direct seeding of the spleen by an infected embolus, often originating from an infected valvular vegetation 1. Uncontrolled diabetes increases susceptibility due to compromised immunity. Clinical features include persistent fever, anorexia, weight loss, abdominal pain, and splenomegaly, which align with this patient's presentation. The "safety pin appearance" or "pin head colonies" in pus culture suggests the presence of a specific bacterial infection.
Clinical Features
- Persistent fever
- Anorexia
- Weight loss
- Abdominal pain
- Splenomegaly
- Leucocytosis
- Anemia
Investigations
- Ultrasound (USG) to diagnose splenic abscess
- Abdominal CT and MRI to confirm diagnosis and evaluate extent of infection
- Blood cultures to identify causative organism
- Pus culture to guide antibiotic therapy
Management
- Splenectomy with appropriate antibiotics is the definitive treatment for splenic abscess, and should be performed immediately unless urgent valve surgery is also planned 1.
- Percutaneous drainage or aspiration of splenic abscess may be an alternative to splenectomy for patients who are poor surgical candidates.
- Antibiotic therapy should be guided by culture results and should cover common pathogens such as viridans streptococci, S aureus, and enterococci.
- Concurrent management of diabetes is essential, requiring insulin therapy to achieve glycemic control.
- Supportive care includes hydration, nutritional support, and treatment of anemia with blood transfusions if severe.
Prevention
- Prevention strategies should focus on preventing bacteremia and endocarditis, such as practicing good hygiene and seeking medical attention promptly if symptoms of infection occur.
- Patient education about protective clothing and insect repellents may also be beneficial in preventing certain types of infections.
From the Research
Etiopathogenesis
- Actinomycosis is a rare chronic disease caused by Actinomyces spp., anaerobic Gram-positive bacteria that normally colonize the human mouth and digestive and genital tracts 2.
- The bacteria can enter the bloodstream and spread to other parts of the body, including the spleen, through various means such as trauma, surgery, or infection 3, 4.
- In the case of the 58-year-old male patient, the uncontrolled diabetes and persistent fever may have contributed to the development of actinomycosis, particularly splenic actinomycosis 5.
Clinical Features
- The patient presents with persistent fever, anorexia, weight loss, abdominal pain, tender splenomegaly, anemia, and leucocytosis, which are common clinical features of actinomycosis 2, 4.
- The presence of a splenic abscess with pus culture showing safety pin appearance/pin head colonies is consistent with actinomycosis 3, 4.
- Actinomycosis can mimic other diseases, including malignancy, and may present with atypical symptoms, making diagnosis challenging 2, 4.
Investigations
- Bacterial cultures and pathology are the cornerstone of diagnosis, but particular conditions are required to get the correct diagnosis 2.
- Prolonged bacterial cultures in anaerobic conditions are necessary to identify the bacterium, and typical microscopic findings include necrosis with yellowish sulfur granules and filamentous Gram-positive fungal-like pathogens 2, 4.
- Imaging studies such as ultrasound and computerized tomography can help identify the location and extent of the infection 4.
Management
- Patients with actinomycosis require prolonged (6- to 12-month) high doses of penicillin G or amoxicillin to facilitate drug penetration in abscesses and infected tissues 2.
- The duration of antimicrobial therapy could probably be shortened to 3 months in patients who have undergone optimal surgical resection of infected tissues 2.
- In the case of splenic actinomycosis, splenectomy may be necessary, accompanied by intravenous and oral penicillin treatment 3, 4.
- Proper and prompt diagnosis of actinomycosis is important because the therapeutic plan and prognosis of this pathogen are quite different from other microorganisms and malignancies 4.