Nonsurgical Treatment of Splenic Abscesses in Patient With Simultaneous Diagnosis of Endocarditis and Crohn's Disease: A Case Report and Literature Review

ABSTRACT

The spleen is one site for septic emboli in cases of IE but in patients with splenic abscess when the patient has a suspicious history of autoimmune diseases, splenic aseptic abscess must be ruled out before splenectomy.

1. Introduction

Splenic abscesses are rare occurrences and are most commonly caused by bacterial infections with an incidence between 0.14% and 0.7% globally. There are fewer than 800 cases reported in the literature regarding splenic abscess. Aseptic splenic abscesses (ASAs) are much less common, with the majority of cases reported from Europe [1]. Infective endocarditis (IE) remains a deadly disease, with approximately 20% mortality rate, despite optimal medical and surgical treatment [2]. One of the rare but well‐recognized complications of IE is the development of splenic abscesses due to systemic septic emboli. Its most frequent pathological manifestations are sessile vegetations that can fragment and generate septic emboli, which can produce distant ischemia and metastatic infection. In left‐sided IE, this occurs in approximately 20%–50% of cases, with the most commonly affected sites being the central nervous system and spleen [2, 3].

ASA is a rare but important clinical entity that affects patients with systemic inflammatory conditions, most often inflammatory bowel disease (IBD). Most patients are misdiagnosed with a bacterial infection and receive unnecessary courses of antibiotics. Patients often undergo unnecessary surgical procedures (e.g., splenectomy), which lead to substantial costs to their well‐being and the overall healthcare system [4].

Spleen has been recognized for its important role in protecting from infection. It contains 25% of total body lymphoid mass and half of the body monocyte and immunoglobulin producing B lymphocytes. Splenic abscess usually results from bacteremia, particularly in the setting of abnormalities caused by trauma, embolization, or hemoglobinopathy. Occasionally, splenic abscess results from extension of a contiguous focus of infection. Classically, IE has been most strongly associated with splenic abscess, and in most series, endocarditis is identified as the leading cause [5]. Although surgical splenectomy is generally the standard treatment for splenic abscess, we explore the effectiveness of conservative management in this context. Percutaneous drainage is typically considered a secondary option for the management of splenic abscesses. Reports of successful treatment with antibiotics alone are uncommon [6].

In this case, we present a patient with aortic valve endocarditis who developed multiple large splenic abscesses and had Crohn's disease simultaneously. Therefore, we treated the patient only with antibiotics, considering the autoimmune background, without performing splenectomy. In the follow‐up, in addition to improving the clinical symptoms, the splenic abscesses also resolved.

2. Case Presentation

A 53‐year‐old male patient was admitted to the hospital with a 2‐month history of fever, weakness, and sweating, along with a 5‐kg weight loss. Upon admission, he presented with hypotension, high fever, tachypnea, tachycardia, and severe weakness. The patient's history revealed swelling and redness of the skin, which had appeared a month ago, and it had been diagnosed as Sweet's syndrome through a biopsy, which was resolved with corticosteroid treatment. In addition, the patient had developed diarrhea about a month and a half ago, which had resolved and was currently free of gastrointestinal symptoms.

3. Methods

On clinical examination, the skin and mucous membranes appeared completely healthy. Neurological examination was normal. The abdominal examination showed no tenderness, and the lung examination was unremarkable. Upon auscultation, a systolic murmur (Grade 3/5) was heard in the aortic valve region. In the joint examination, there was mild swelling of the second proximal interphalangeal joint of the left hand, but no arthralgia was noted.

In this admission, blood pressure was 60/40 mmHg, pulse rate was 110/min, temperature was 38.8°C, O₂ saturation was 96% in room air, and the respiratory rate was 27/min.

3.1. Examinations That Were Previously Performed on an Outpatient Basis

The colonoscopy, which was performed 15 days before admission, was reported as normal with an erythematous region in the ileum. The colonoscopy pathology result was not yet ready. A month and a half ago, the patient had an abdominal‐pelvic CT scan, which was normal.

The following results were obtained in the examinations and tests that were performed after the patient was hospitalized (Table 1).

TABLE 1.

Laboratory data.

Lab data	Result	Standard units of the values
WBC	20	4.4–11
Neutrophil	85%	35%–75%
Hb	6	14–17.2
PLT	230	150–420
AST	35	10–40 (IU/L)
ALT	40	10–40 (IU/L)
ALK	215	44–147 (IU/L)
ESR	50	0–15 mm/h
CRP	110	0.3–1.0 mg/Dl
Wright test	Negative	Under 1/40
2ME	Negative	Under 1/40
Coombs Wright test	Negative	Under 1/40
HIV test	Nonreactive
Blood culture in two separate set	Streptococcus viridans

Abbreviations: ALK: alkaline phosphatase, ALT: alanine transaminase, AST: aspartate aminotransferase, CRP: C‐reactive protein, ESR: erythrocyte sedimentation rate, Hb: hemoglobin, PLT: platelet, WBC: white blood cells.

Necessary examinations that were performed on this hospitalization including an echocardiogram and CT scans of the chest and abdomen with oral and intravenous contrast were recorded. The results were as follows:

• Chest CT: normal.

• Abdominal CT: three collections were seen in the spleen (Figure 1).

• Abdominal‐pelvic CT with IV and oral contrast: did not have any additional information.

• Transthoracic echocardiography: normal.

FIGURE 1.

The abdominal CT scan showed three collections in the spleen.

An ultrasound of the spleen was requested for aspiration, and samples were sent for culture and analysis. Due to the persistent fever, the patient was scheduled for a follow‐up consultation and was considered for a transesophageal echocardiogram (TEE).

Given the patient's condition upon admission, antibiotic treatment with meropenem 1 g every 8 h (TDS) intravenous infusion and vancomycin 1.5 g stat (loading dose) and then 1 g every 12 h (BD) intravenous infusion was administered while awaiting blood culture results, and hematological consultation was performed based on laboratory data, including anemia and leukocytosis. A peripheral blood smear was examined and found to be normal. However, 2 days after starting antibiotics, while vital signs had stabilized and general condition was improving, the patient developed thrombocytopenia. Platelets had dropped below 25,000 without bleeding. Following a repeat hematology consultation, intravenous immunoglobulin (IVIG) was administered and vancomycin was discontinued, leading to correction of the thrombocytopenia.

Additionally, considering the patient's history of diarrhea, the patient had undergone colonoscopy. The pathology report from the colonoscopy, which was performed 15 days before admission, was still pending. The patient had a history of a dental abscess and underwent dental surgery and implant placement before the onset of fever. The patient improved after 10 days of antibiotic treatment, and once the blood culture results were available, the antibiotic regimen was adjusted accordingly and meropenem 1 g BD only continued. The culture from the aspirated splenic collection returned negative. TEE revealed a 6‐mm vegetation on the ventricular side of the aortic valve, confirming the diagnosis of endocarditis (Figure 2). After several days of antibiotic treatment, the pathology report from a colonoscopy performed 15 days before admission indicated Crohn's disease, prompting the initiation of appropriate treatment including mesalamine and budesonide.

FIGURE 2.

Aortic valve endocarditis vegetation.

4. Discussion

Splenic abscess, comprising one or more focal collections of bacterial, mycobacteria, or fungi, is an uncommon disorder due to bacteremia, particularly in the setting of splenic abnormalities caused by trauma, embolization, or hemoglobinopathy or result from extension of a contagious focus of infection [7]. Rarely ASA due to inflammatory disorder can cause splenic collection that misdiagnose with septic splenic abscess [8]. Splenic abscesses can occur as a complication of IE, which can aggravate the disease and increase mortality. Systemic embolization occurs in about 20%–50% of cases of IE affecting left‐sided heart valves. Although splenic embolic events are often tolerated, they can lead to severe complications such as splenic infarction, hemorrhage, rupture, and abscess formation [9]. Bacterial endocarditis is an uncommon cardiac complication of IBD. ASA also can be the first manifestation of IBD, especially Crohn's disease, with gastrointestinal symptoms [10]. Splenic abscesses can be life‐threatening, with a mortality rate exceeding 20%. Symptoms may include nausea, vomiting, tenderness in the left flank or upper quadrant, and hiccups, but many patients remain asymptomatic. Up to 90% of patients may not show any local symptoms, often presenting only with persistent or recurrent fever [9]. Diagnosis typically relies on noninvasive imaging, with CT and MRI providing greater accuracy compared to ultrasound [11].

Management of IE complicated by splenic abscess may involve antibiotics, splenectomy, and valve replacement surgery. Splenectomy is often recommended prior to valve replacement to reduce the risk of reinfection [12]. ASA is a rare but important clinical entity that affects patients with systemic inflammatory diseases, the most common of which is IBD. Most patients are misdiagnosed with bacterial infections and receive unnecessary courses of antibiotics. Patients often undergo unnecessary surgical procedures (e.g., splenectomy), which results in significant costs to their well‐being and to the healthcare system as a whole [4]. Until now, there have been no reports of splenic abscess in the setting of concurrent IE and IBD.

We found few case reports in the literature where a splenic abscess due to IE was successfully treated with antibiotics alone [8]. We reported the first case of splenic abscess in the context of simultaneously IE and IBD. He presented with a 2‐month history of fever and malaise, and he was admitted to the hospital while the vital sign was unstable. One month ago, he had shown signs of digestive tract inflammation, such as diarrhea; changes in stool characteristics; and sweet syndrome but they disappeared. Despite the treatment option for splenic abscess in the context of endocarditis is splenectomy, due to the patient's concurrent IBD and negative culture of the splenic abscess, we treated the patient only with antibiotics without splenectomy.

In summary, splenic abscesses in the context of IE can lead to serious complications and a high risk of mortality, which necessitates timely diagnosis and treatment. Treatment options typically include antibiotics and either surgical or image‐guided interventions. In the other hand, ASA did not need to antibiotic treatment and splenectomy. In our case, it is demonstrated that antibiotic treatment alone can manage multiple large splenic abscesses in selected patients with concurrent IE and IBD. However, caution is warranted when choosing antibiotics alone for large abscesses in the setting of IE. An individualized approach based on clinical factors and the patient's response to antibiotics is recommended for managing these complex cases. Although our successful management in this case may indicate that early splenectomy with splenic abscess is not always necessary in patients with IE and IBD, caution is advised.

5. Conclusion and Results

Due to the negative culture and PCR result from the splenic abscess, a splenectomy was not performed and only antibiotic therapy was administered for 6 weeks. At the end of the treatment period, three collections were still observed on ultrasound. Therefore, the patient was monitored after discontinuing antibiotics. Four weeks after patient discharge, during a follow‐up ultrasound, the abscesses had resolved, and a repeat echocardiogram showed a reduction in the size of the vegetation. The patient was monitored for 6 months and had no problems during this period.

In summary, splenic abscesses in the context of IE can lead to serious complications and a high risk of mortality, which necessitates timely diagnosis and treatment. Treatment options typically include antibiotics and either surgical or image‐guided interventions. In the other hand, ASA does not need antibiotic treatment and splenectomy. In our case, it is demonstrated that antibiotic treatment alone can manage multiple large splenic abscesses in selected patients with concurrent IE and IBD. However, caution is warranted when choosing antibiotics alone for large abscesses in the setting of IE. An individualized approach based on clinical factors and the patient's response to antibiotics is recommended for managing these complex cases. Although our successful management in this case may indicate that early splenectomy with splenic abscess is not always necessary in patients with IE and IBD, caution is advised.

Author Contributions

Shiva Shabani: conceptualization, data curation, formal analysis, investigation, supervision, validation, writing – review and editing.

Consent

Written informed consent has been obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Data Availability Statement

The data during the current study are available from the corresponding author on reasonable request.