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Splenic microabscesses in the immune-compromised patient
R M Hatley1, J S Donaldson, J G Raffensperger
1Department of Surgery, Children's Memorial Hospital, Northwestern University Medical School, Chicago, IL 60614.
Abstract:
Four immune-compromised children who were receiving antineoplastic chemotherapy (three for leukemia), presented with recurrent episodes of fever and left upper abdominal pain. Blood cultures grew enteric gram-negative organisms in three children. Multiple blood cultures were negative for fungus although three patients had mucocutaneous and urinary candidiasis. All remained febrile and symptomatic despite treatment with broad spectrum antibiotics and antifungal chemotherapy. Computed tomography (CT) scans in all patients showed 2- to 10-mm focal defects in the spleen. The larger defects could be seen by ultrasonography but not on the live-spleen nuclear scan. A splenectomy was performed 2 to 4 weeks after the onset of symptoms in each child, and the cut surface of the spleens showed multiple small abscesses. All operative cultures were negative. A histological examination confirmed Candida infection in two patients and Aspergillus in one. Necrotizing granulomas strongly suggestive of fungus were seen in the fourth child. The patients defervesced and appeared well within three days. Antifungal therapy was continued. One child remains in remission from acute lymphocytic leukemia; one continues on chemotherapy; and one has recurrent widespread tumor. The patient with Aspergillus died following a bone marrow transplantation 6 months after the splenectomy. He had disseminated aspergillosis. An immune-compromised patient with persistent unexplained fever should have a CT scan of the abdomen. The presence of multiple splenic lesions strongly suggests fungal disease. If antifungal therapy does not result in complete resolution of fever and the splenic lesions, a splenectomy is indicated.
Insights
Splenic abscesses in immunocompromised children treated with chemotherapy can be challenging to diagnose. Early CT scans and, if necessary, splenectomy are crucial for managing fungal infections.
Area of Science:
- Pediatric Infectious Diseases
- Medical Imaging in Oncology
- Surgical Management of Splenic Abscesses
Background:
- Immunocompromised children undergoing antineoplastic chemotherapy are susceptible to opportunistic infections.
- Recurrent fever and abdominal pain in these patients warrant thorough investigation for intra-abdominal pathology.
Observation:
- Four pediatric patients on chemotherapy presented with persistent fever, abdominal pain, and negative fungal blood cultures despite mucocutaneous and urinary candidiasis.
- Computed tomography (CT) scans revealed multiple splenic focal defects, suggestive of fungal infection, which were not clearly visualized by ultrasonography or nuclear scans.
Findings:
- Histological examination of spleen specimens post-splenectomy confirmed fungal infections (Candida and Aspergillus) in three of the four children.
- Splenectomy led to rapid defervescence and clinical improvement in all patients, despite negative operative cultures.
Implications:
- Persistent unexplained fever in immunocompromised patients necessitates abdominal CT to identify splenic lesions.
- Multiple splenic lesions on CT are highly indicative of fungal disease.
- Splenectomy is a potentially life-saving intervention for fungal splenic abscesses unresponsive to antifungal therapy.