Splenic abscess due to acute pyelonephritis

Description

We present a case of a 63-year-old woman with hypertension and diabetes mellitus, who was admitted for left lumbar pain, fever (38.5°C) and nausea. Abdominal ultrasound revealed several heterogenous splenic nodules and an enlarged left kidney with a 7 mm calculus in the medium pyelocaliceal system. Contrast enhanced ultrasound showed multiple simple splenic cysts and a nodule in the inferior pole, with rapid arterial peripheral enhancement (figure 1A), enhancement in the late phase (figure 1B) without washout, with irregular contour, inner septum and possible central necrosis. Abdominal CT showed a 21 mm, heterogeneous, hypodense nodule in the inferior splenic pole (figure 2A), and inflammatory densification of perirenal fatty tissue with thickening of the perirenal fascia (figure 2B).

Figure 1.

(A) Arterial phase of contrast enhanced ultrasound (CEUS) and (B) late phase of CEUS.

Figure 2.

(A) CT scan of splenic abscess and (B) CT scan of pyelonephritis.

Biologically, the patient presented with leukocytosis, hyperglycaemia and inflammatory syndrome. Urinary cultures were negative; blood cultures grew Streptococcus spp. The patient received antibiotic treatment and the symptoms and ultrasound aspect improved in about 2 weeks.

We conclude that the patient presented splenic abscess due to acute pyelonephritis. Diabetes is a risk factor for this rare condition; splenic abscesses may appear by haematogenous metastasis or contiguity.¹ Other cases² showed improved outcome by splenectomy; in our case this was not required, as the patient's evolution was satisfactory under antibiotic treatment. Although there are no pathognomonic symptoms, in patients with high suspicion of infection who present with abdominal pain, fever and nausea, splenic abscesses are diagnoses to be considered.³

Learning points.

• Splenic abscess is a rare and severe complication of acute pyelonephritis.

• It is important to diagnose it quickly, despite the fact that it is difficult to establish the pathogenesis.

• Antibiotic treatment improves outcome.