編輯委員大鑑
本人提出〝長期血液透析病人之隱匿性脾膿腫引起持續發燒〞
( Persistent fever in a patient on long-term hemodialysis : occult splenic abscess )
文章，如蒙審查通過，希望能在台灣腎臟
醫學會雜誌刊登發表。
謹祝 學安
作者：曾金鳳 醫師
耕莘醫院 腎臟科
2009/9/12
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Persistent fever in a patient on long-term hemodialysis : occult splenic abscess
Authors:
Cai-Mei Zheng 1 , Kuo-Cheng Lu 1 , Jing-Quan Zheng 1 , Li-Kiang Yang 1 ,
Yin-Sheng Chen 1 , Hsiang-Chun Jan 2 , Fur-jiang Leu 3 , Chia-Mei Chen 4 ,
Chin-Feng Tseng 1
Running title: Splenic abscess in a hemodialysis patient
Key words: fever of unknown origin, splenic abscess, diabetes mellitus, hemodialysis
Institution:
Division of Nephrology, Department of Medicine 1 , Department of
Surgery 2 , Department of Pathology 3 , Department of Radiology 4 ,
Cardinal-Tien Hospital, School of Medicne, Fu-Jen Catholic University
Address reprint requests and correspondence:
Chin-Feng Tseng, MD
Division of Nephrology, Department of Medicine, Cardinal-Tien
Hospital, School of Medicne, Fu-Jen Catholic University
No 362, Chung-Cheng Rd, Hsin-Tien City, Taipei county, Taiwan 23137
Tel: (02) 22193391 ext 65340 Fax: (02) 29107920
E-mail: ttwyl123@yahoo.com
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Abstract
Splenic abscess is relatively rare and may be easily missed. It is more often encountered in immunocompromised patients, such as patients with end-stage renal disease (ESRD) who are on long-term dialysis, particularly those with concomitant diabetes. When these patients develop fever of unknown origin, they may have atypical presentations and are easily susceptible to infection by atypical organisms which might delay detection and diagnosis. We present a diabetic patient with ESRD on long-term hemodialysis who developed persistent fever and left-sided pleural effusion. He was eventually found to have splenic abscess and the infecting microorganism was S erratia marcescens. Injection antibiotics with exploratory splenectomy done and his fever subsides.
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Introduction
Infection is a common cause of mortality and morbidity in patients on long term dialysis, particularly when associated with diabetes mellitus.
Fever is the most common clinical manifestation of sepsis in these patients. Splenic abscess is an uncommon source of sepsis in patients on long-term dialysis, much less in the general population, but is potentially life-threatening if left undetected. In dialysis patients with fever of unknown origin (FUO), splenic abscess should be considered as a possible source of infection. We present a diabetic patient with end-stage renal disease on maintenance hemodialysis who developed prolonged unexplained fever and left-sided pleural effusion. He was eventually found to have occult splenic abscess.
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CASE REPORT
Our patient is a 64 year-old male diabetic patient with end-stage kidney disease who has been on regular maintenance hemodialysis for 13 years. He was referred to our hospital ER because of intermittent mild fever of two months’ duration. Four months prior to this referral, he had undergone wound debridement for bilateral malignant otitis externa.
Subsequently, he had regular follow-ups at the Otorhinolaryngology
(ENT ) clinic for management of complicated suppurative otitis media with perforated tympanic membrane. Initial examination revealed purulent discharge from both ears, and body temperature was 38°C. But he looked quite comfortable and was in no apparent distress.
Laboratory investigations included white cell count 21.6 x 10 9 /L, hemoglobin 9.2g/dl, platelet count 126,000/mm 3 , blood urea nitrogen 70 mg/dl, serum creatinine 3.28 mg/dl, serum sodium and potassium were
132 and 4.7 mmol/l respectively. His C-reactive protein was 23 mg/dl, and glycated hemoglobin 9.4g/dl. Chest radiography and other investigations were within normal limits.
Blood and ear discharge samples were collected for culture and sensitivity testing (C&S) and empirical intravenous (IV) antibiotics with
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ampicillin/sulbactum were given. Regular hemodialysis was continued for diabetic nephropathy. Topical ear antibiotic solutions were used to help eliminate secondary bacterial pathogens. Culture of ear discharge isolated Pseudomonas aeruginosa , and antibiotic regimen was changed to piperacillin. Blood culture failed to isolate any microorganism but his fever still persisted after 2 weeks of intravenous antibiotic therapy. He complained of left lower chest wall discomfort and a chest film showed left pleural effusion (Fig. 1). Abdominal ultrasonogram was done (Fig. 2) and revealed left sided pleural effusion as well as infra-diaphragmatic fluid and a splenic cyst. Serous pleural fluid was obtained upon diagnostic chest tapping. Abdominal computed tomography (CT) examination (Fig. 3) with CT-scan guided aspiration of the cyst was done subsequently and pus was drained from the splenic cyst. Splenic abscess was diagnosed and antibiotic therapy was shifted to IV meropenem. The diagnosis was discussed with the patient and his immediate family and splenectomy was suggested. Possible hematologic sources of splenic abscess were investigated and a cardiac echogram was done to rule out endocarditis. Catheter-related sepsis was also ruled out. The patient agreed to undergo splenectomy which was done on the 17 th hospital day
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after immunization against Streptococcus pneumoniae, Meningococcus, and Haemophilus influenzae type b. An abscess measuring 4cmx 3cmx
1.3cm with rupture to the surface was noted. (Fig. 4)
Biopsy and pathological results came out as polymorphonuclear infiltrates with necrotic, hemorrhagic necrosis in the center of the abscess.
(Fig.5,6). His condition gradually improved and defervescence was noted starting on the 20 th hospital day (3 days post-splenectomy) .
Aerobic culture of the splenic abscess isolated Serratia mercesens which was sensitive to the antibiotics used. Antibiotic therapy was continued for 2 weeks after splenectomy. He was discharged in stable condition on the
14 th post- operative day.
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Discussion
Our patient had poorly controlled diabetes mellitus with end-stage renal disease and was on regular maintenance hemodialysis. He also had chronic otitis media (COM) which was partially treated with antibiotics prior to this admission. Upon admission, parenteral antibiotic therapy was targeted to control infection related to COM. However, persistent fever with left-sided pleural effusion prompted further investigation for a probable systemic source of infection. Abdominal sonogram and CT scan were done subsequently and a splenic cyst was found from which pus was aspirated under CT guidance. Thus, a diagnosis of splenic abscess was established.
The spleen is an uncommon site of abscess formation. Multilocular abscesses are frequently encountered in younger patients who are often immunosuppressed or have problems with drug abuse.
In contrast, a unilocular splenic abscess is the most common presentation in patients more than 70 years old, and diabetes mellitus is the most usual comorbidity (1).
The mortality rate is high and may be 100% if the splenic abscess is not detected and treated promptly. Thus, early diagnosis and treatment is life-saving.
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Common causes of splenic abscess include metastatic bacteremic spread (eg.infective endocarditis, otitis, pneumonia), contiguous spread
(e.g., pancreatic infection or cancer, gastric ulcer or cancer, perihepatic abscess, subphrenic absess,diverticulitis, etc.), traumatic injury, hematologic disorders (e.g. collagen-vascular diseases, sickle cell anemia), and states of immunodeficiency as in AIDS, chemotherapy, cancer, long term steroid use, diabetes mellitus, alcoholism, etc (1) .
Fever of unknown origin (FUO) is a common problem in patients on long-term dialysis due to their immunocompromised status. Those patients (especially the elderly) with concomitant diabetes mellitus (2) and poor nutritional status are particularly susceptible to septicemia.
Although splenic abscess is rare in patients on long-term dialysis, catheter-related staphylococcus and salmonella septicemia (3) and septic embolization from infective endocarditis (1,4) are common sources of splenic abscess in these patients.
Clinically, patients with splenic abscess present with fever (>90%) , abdominal pain (>50%) and LUQ tenderness (>40%) which usually lasts for 2-4 weeks or longer (subacute in nature) (1,5,6). Anorexia and malaise may also be present, and most patients have leukocytosis. Since
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most patients found to have splenic abscess have underlying illnesses and predisposing risk factors (e.g., endocarditis, pancreatitis, neutropenia, and intravenous use of illicit drugs,etc) the localizing signs of splenic abscess may be inapparent and are often overlooked.
The most common organisms isolated from splenic abscesses are
Staphylococcus aureus, Streptococci and families of Enterobacteriaceae
(1,5). The only case report of splenic abscess due to Morganella morganii and Serratia marcescens infection was recently described in a hemodialysis patient who initially presented with unexplained pleural effusion (6).
Our patient had chronic otitis media and concomitant splenic abscess.
Serratia marcescens was cultured from the splenic abscess but blood culture was sterile. Blood culture is reported to be positive only in 59.7% of patients and the same microorganism was isolated from both blood and splenic abscess cultures in 74% of patients (1).
We suspect that prior antibiotic treatment for COM may be the reason why blood culture failed to isolate any microorganism in our patient.
Serratia marcescens is a Gram-negative, rod-shaped bacterium that belongs to the family Enterobacteriaceae. It is commonly involved in
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nosocomial infections, particularly catheter-related bacteremia, urinary tract infections, and wound infections. To date, Serratia marcescens is not a well-known cause of splenic abscess in most literature reviews.
Diagnosis of splenic abscess is difficult. Plain radiographs may reveal a left-sided pleural effusion or infiltrates, but these findings are non-specific. Abdominal CT or MRI is preferred for investigation (1,7).
With CT scanning, a splenic abscess may appear as gas, or subcapsular extension with free adjacent fluid. Early empirical parenteral broad-spectrum antibiotic therapy after blood cultures have been drawn is life-saving (7).
Aside from the commonly associated microorganisms, therapy directed against mycobacteria, Candida, fungal abscesses and
Aspergillus should also be considered in immunocompromised patients.
Surgical drainage is the optimal management for splenic abscesses except for small pus collections and in selected cases. Percutaneous drainage is indicated for easily-accessed uniloculated or biloculated abscesses and in patients with high surgical risks (8,9).
Splenectomy is the standard procedure for complete removal of splenic abscesses. Open splenectomy enables removal of the septic source and
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coexisting septic collections. Laparoscopic splenectomy is safe but patients should be in relatively stable condition.
Management for our patient included empirical IV antibiotics, exploratory splenectomy, and tight control of underlying diabetes mellitus.
In conclusion, patients on long-term dialysis presenting with FUO should be investigated for possible systemic (and occult) sources of infection, especially if no obvious focus of infection is evident. In patients presenting with FUO and left-sided pleural effusion, the possibility of an occult splenic abscess should always be kept in mind.
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References
1.
David Schlossberg. Current Therapy of Infectious Disease.
Philadelphia; WB Saunders, 2002; 201-204.
2.
Neil R.P, Bernard J, Susan L.F, Judith H, and William B: Septicemia in dialysis patients: Incidence, risk factors, and prognosis. Kidney Int
1999; 55: 1081-1090
3.
Nakamura T, Iwashima A, Honma T et al . Splenic abscess in a patient on hemodialysis. Nephron 1992; 60: 255–256
4.
Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation.
1998;
98(25): 2936-2948.
5.
Fonseca V, Baillod R, Berger L et al . Splenic abscess in patients on hemodialysis. Am J Kidney Dis 1990; 15: 273–275.
6.
Inge Hamming, Kenrick Berend, Nouaf Ajubi, Rauf Engels and
Willem Develter. An unusual cause of pleural effusion in a haemodialysis patient. NDT Plus 2009; 2: 164–166
7.
Chang KC, Chuah SK, Changchien CS et al . Clinical characteristics and prognostic factors of splenic abscess: a review of 67 cases in a
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single medical center of Taiwan. World J Gastroenterol 2006; 12:
460–464.
8.
Zerem E, Bergsland J. Ultrasound guided percutaneous treatment for splenic abscesses: The significance in treatment of critically ill patients. World J Gastroenterol . Dec 7 2006;12 (45):7341-5.
9.
Ferraioli G, Brunetti E, Gulizia R, et al. Management of splenic abscess: report on 16 cases from a single center. Int J Infect Dis . Dec
11 2008.
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Fig 1. Elevated left hemidiaphragm and left pleural effusion
Fig 2. Hypoechoic ovoid-shaped area in the spleen, with irregular poorly-defined borders and varying internal echogenicity; splenic abscess or infected cyst was suspected.
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Fig 3. Homogeneous low-density area; lucent areas within the spleen containing fluid with sub-capsular extension
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Fig 4. Spleen-abscess; The arrow shows the abscess exhibiting a necrotic center and irregular light yellow margins.
Fig 5. Spleen-abscess (x100); The arrow shows the irregular fibrotic wall surrounding the necrotic, hemorrhagic center.
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Fig 6. Spleen-abscess; High power (x400) view of the necrotic, hemorrhagic center of the abscess.
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長期血液透析病人之隱匿性脾膿腫引起持續發燒
鄭彩梅 盧國城 鄭景泉 楊麗瓊 陳應盛 冉祥俊 呂福江
陳嘉美 曾金鳳
長期接受血液透析的病人最常見的罹病和死亡的原因為感染，尤
其有糖尿病的患者發生率更高，而發燒是感染症最常見的臨床表現。
無論是一般人或是接受洗血液透析的病人，脾膿腫是一種少見的敗血
症感染來源，而且如果不及早診治，可能危及生命。我們報告一例糖
尿病合併末期腎病患者接受長期血液透析治療，因為不明原因的發燒
而住院，經診斷為中耳炎接受靜脈抗生素治療，但因高燒不退，且左
胸腔出現積液，最後被診斷為隱匿性脾膿腫。細菌培養結果為罕見之
黏質沙雷氏菌
( Serratia marcescens )
，
病患接受手術及抗生素治療得以
痊癒。
關鍵字： 不明原因發燒，脾膿瘍，糖尿病，血液透析
耕莘醫院 內科部 腎臟科
抽印本索取 : 曾金鳳醫師
台北縣新店市中正路 362 號 耕莘醫院腎臟科
電話 :02-22193391 轉 65340
傳真 :02-23310878
電子信箱 : ttwyl123@yahoo.com
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