Typhoid splenic abscess : a rarity in the present era

Typhoid fever is a major public health problem in South East Asia and has multiple complications involving almost every major organ system of the body. Abscess of the spleen is an uncommon complication of typhoid fever in the present era due to effective use of antibiotics. It is often fatal if not recognized in time. The conventional treatment is surgical drainage of the abscess which is associated with significant morbidity. We present a case of splenic abscess due to Salmonella enterica serotype Typhi, in a previously healthy individual which was managed conservatively by percutaneous aspiration


Introduction
Splenic abscess is an unusual complication of enteric fever in the post antibiotic era.The overall incidence of splenic abscesses varies from 0.14-0.7%as per various studies. 1 Common causes of splenic abscess include bacterial infections, abdominal trauma, splenic infarctions, hemoglobinopathy and immune-compromised states such as HIV, organ transplants and neoplastic diseases. 2The infective diseases where splenic abscess has been reported include pneumonia, bacillary dysentery, infective endocarditis, urogenital infections, and rarely tubercular, amoebic or fungal infections.[5][6] The majority of typhoid splenic abscesses are solitary, but multiple abscesses occur in a small number of patients. 7Best treatment options remain unclear.Percutaneous drainage may be appropriate in some patients, but may fail in inexperienced hands and splenectomy remains the standard therapy.In general, a solitary splenic abscess can be managed with antibiotics and percutaneous drainage.However, those with multiple abscesses or thick pus with septations and those not responding to percutaneous drainage require splenectomy to prevent mortality. 8A high index of suspicion is required as the classical triad of fever, left upper quadrant tenderness and splenomegaly occur only in 32-50% cases We report a rare case of typhoid fever with splenic abscess in a young immune competent male who was successfully managed with antibiotics and repeated ultrasonography guided percutaneous pus drainage on three occasions .

Case report
A 20 year old male presented to without chills and rigors and diarrhea of quadrant pain two days prior to presentation.had tachycardia (pulse rate 110/min) and left upper quadrant tenderness.Laboratory tests revealed bicytopenia (TLC:3700/uL; (AST:159; ALT:154) with normal Blood culture grew Salmonella enterica Ultrasonography of abdomen showed multiple heteroechoic lesions in the spleen.Contrast enhanced computerized tomography of (Fig 1 ) showed multiple splenic lesions (largest measuring 7.0x5.8x4.3cm) in the splenic parenchyma, predominantly subcapsula in location Hemoglobin electrophoresis was normal.2D echo showed normal valves and no vegetations.Screen for HIV was negative.He was started on intra venous ceftriaxone and aspirate was obtained on drainage of under ultrasonography (US) guidance culture was sterile.After 5 days, the antibiotics were changed to piperacillinamikacin as he continued to be febrile.Whole body positron emission tomography a hypodense, hypometabolic cystic lesion measuring 7.8 x 6.0 x 7.4 cm in the superior pole of spleen (Fig 2 ) with two small lesions below the abscess.There was no other area of flourodeoxyglucose (FDG) avid uptake noted.In view of persistent fever and large residual abscess despite antibiotics and US guided percutaneous drainage, the option of splenectomy was considered and discussed with the relatives.In view of his age and long term consequences of splenectomy, it was decided to adopt a spleen conserving approach and repeated SLJID • www.http://sljol.info/index.php/SLJID• Vol. 5, No. 2, October 2015 index of suspicion is required as the classical triad of fever, left upper quadrant tenderness and 50% cases. 2se of typhoid fever with splenic abscess in a young immune competent male who was successfully managed with antibiotics and repeated ultrasonography guided percutaneous pus drainage on three occasions .
A 20 year old male presented to a tertiary care hospital in New Delhi with continuous fever without chills and rigors and diarrhea of five days duration.He gave a history of vague left upper days prior to presentation.On clinical examination, he was febrile (102 (pulse rate 110/min) and left upper quadrant tenderness.Laboratory tests revealed bicytopenia (TLC:3700/uL; platelet count:90,000/ul), mild transaminase elevation ALT:154) with normal serum bilrubin.Screen for malaria and dengue Salmonella enterica subspp enterica serotype Typhi.
abdomen showed multiple spleen.Contrast computerized tomography of abdomen showed multiple splenic space occupying x5.8x 4.3cm) in the predominantly subcapsular Hemoglobin electrophoresis was normal.2D echo showed normal valves and no vegetations.
HIV was negative.He was started on eftriaxone and 90 ml purulent on drainage of the abscess guidance.The pus culture was sterile.After 5 days, the antibiotics -tazobactam and he continued to be febrile.Whole on emission tomography scan showed a hypodense, hypometabolic cystic lesion measuring 7.8 x 6.0 x 7.4 cm in the superior pole of spleen (Fig 2 ) with two small lesions below the abscess.There was no other area of avid uptake noted.In view of persistent fever and large residual abscess despite antibiotics and US guided the option of splenectomy was considered and discussed with In view of his age and long term consequences of splenectomy, it was decided to spleen conserving approach and repeated  CECT abdomen showing a splenic abscess measuring 7.0x5.8x4.3 cm in the superior pole of US guided aspirations were done on two occasions draining 120 ml and 150 ml pus on successive days.He developed a small left sided pleural effusion which resolved with treatment.The patient responded well to antibiotics and US guided percutaneous drainage and was discharged in a stable condition after three weeks.On subsequent follow up he remained asymptomatic and the US abdomen has shown no residual abscess after 3 months.

Discussion
Splenic abscess is a rare disease and is often fatal if untreated.The incidence of splenic abscess is increasing in recent times due a large number immune compromised patients and improved detection due to widespread use of sophisticated imaging modalities in diagnostic work up of patients with pyrexia of unknown origin.
Atypical manifestations of typhoid fever are being reported more often now than earlier and can occur even during the early phase of disease. 6The manifestations can be intestinal or extraintestinal with the hepato-biliary system and the spleen being among the frequent sites of abdominal salmonellosis. 9The incidence of splenic abscesses in typhoid fever decreased from 2% in the preantibiotic era to less than 1% post introduction of effective antibiotics. 10Sickle cell disease, IV drug abuse, subacute bacterial endocarditis, diabetes mellitus and immunodeficiency are common predisposing factors. 11In a series of 16 patients of splenic abscesses reported by Giovanna Ferraioli et al (2008), none of the cases were associated with typhoid fever and the most common cause was due to other bacterial pathogens. 12The severity of the infection does not appear to play a role.In up to 20% of patients with typhoidal splenic abscess, the pus is sterile while S. Typhi is isolated from blood culture in 40-50% of cases.The diagnosis in endemic regions therefore rests upon a high index of suspicion in individuals presenting with fever, vague left upper quadrant pain and probably a palpable mass with supporting imaging evidence of a splenic space occupying lesion with positive blood cultures. 11There have been case reports of splenic abscesses due to S. Paratyphi A but they are less common as compared to S Typhi. 13In the past, antibiotic therapy and splenectomy were the only available treatments, both of which were associated with significant mortality. 14However, current therapeutic strategies in cases of trauma and benign splenic lesions have established spleen-preserving treatment.Thus, percutaneous drainage of splenic abscesses is being used instead of splenectomy with good results.The advantages of percutaneous drainage are a lesser risk of intra-abdominal spillage, avoidance of perioperative complications and better acceptance by the patient. 15

Conclusions
Splenic abscesses are rare and these complicating typhoid are even rarer.These atypical manifestations can occur early and a high index of suspicion is required for diagnosis which can be confirmed by imaging.Treatment includes antibiotics as per sensitivity pattern of the causative agent.Splenectomy remains the mainstay of treatment in seriously ill patients, those with multiple abscesses or those not responding to medical therapy.Percutaneous drainage can be used with good results as was done in our case and should be attempted in a sub group of hemodynamically stable patients to conserve an important organ.

Fig 2 :
Fig 2 : FDG whole body PET scan showing a hypodense, hypometabolic lesion measuring 7.8 x 6.0 x 7.4 cm in superior pole of spleen.