1550 - Beyond Skin Deep: Cellulitis Induced Splenic Abscess

Background: A 51 year old male presented with splenic abscess from chronic eczema with cellulitis.Coronal plane view of the CT abdomen showing the splenic abscess.
CT abdomen without contrast in the transverse plane showed a splenic mass measuring 7.8 x 8.8 x 6.9 cm, similar in size to the results found on ultrasound examination.


Methods: The patient had poor medical compliance, diabetes, hypertension, hyperlipidemia, COPD, and chronic eczema with cellulitis presented with fever, malaise, abdominal pain and distension. The patient denied any previous intravenous drug use.
CT abdomen showed a splenic mass measuring 7.8 x 8.8 x 6.9 cm. A TTE showed normal ejection fraction and normal mitral valve structure and function. The patient underwent a CT guided drainage with tube placement in the spleen. MRI of the spine showed some osteomyelitis of the L4 vertebrae, which likely developed from the splenic abscess. Subsequent cultures of the splenic abscess showed MRSA.Abdominal ultrasound with 2-D grayscale sector imaging shows a cystic mass in the spleen measuring roughly 8 x 8 x 6.5 cm in dimensions. No vascular flow was identified within the mass.
CT chest showed a prominent left sided pleural effusion, lower lobe lung consolidation air bronchograms. An air-filled and regular cystic area in the posterior dependent portion of the left lower lobe was noted (possibly a small pneumatocele). Patchy infiltrates in right lung were noted as well.


Results: Endocarditis is the most common primary source of splenic abscess, with urinary tract infections, appendicitis, pneumonia, and wound infections as other primary etiologies. Organisms that can be involved are Streptococci, Staphylococci, and Escherichia coli, Enterococcus and Klebsiella pneumoniae.
Splenic abscess follows a bimodal distribution, occuring in those younger than 40 and older than 70 years of age.
Leukocytosis can be as high as the 18,000 cells/mL range or within the upper range of normal limits. The sensitivity of abdominal ultrasonography in the diagnosis of splenic abscesses is roughly 75-93%. The abdominal CT diagnostic sensitivity for splenic abscess ranges from 92-96%. In tandem with the ultrasound examination, the diagnostic sensitivity is estimated at 94.7%.
Treatment options entail intravenous antibiotics with CT-guided percutaneous aspiration or splenectomy. Previous studies noted a 70.8-100% mortality rate in patients with splenic abscess who were treated only with intravenous antibiotics.
 MRI of the spine with contrast showing some probable small osteomyelitis of L4 vertebrae at the anterior/inferior corner.


Conclusion: Characteristics of the patient population, geographic location, recent travel, possible vector exposures, predisposing medical conditions, and individual behaviors may be contributing factors in regards to the underlying etiologic organism(s) involved in each individual case of splenic abscess. This case study is especially rare in that the etiology of the splenic abscess was chronic eczematous cellulitis.