Pyogenic splenic abscess in an infant with serological evidence of cat scratch disease

Abstract

AbbreviationsCSD cat scratch disease PCR polymerase chain reaction CT computed tomographyPyogenic splenic abscess is a rare intraperitoneal infection caused by a variety of bacteria, with S. aureus and streptococci most commonly isolated. Splenectomy is indicated when it is resistant to antimicrobial therapy. We report on a pyogenic splenic abscess requiring repeated aspiration in an infant who was serologically diagnosed as having cat scratch disease (CSD). A 7-month-old boy was admitted to a general hospital due to intermittent low-grade fever of 2 weeks' duration, splenomegaly and multiple cystic lesions in the spleen detected by ultrasonography. Despite intravenous administration of cefotaxime on suspicion of splenic abscess, high fever persisted and the intrasplenic lesions expanded. Five days after admission, he was referred to our hospital. There was no history of the presence of a pet. On physical examination, anemia and splenomegaly were noted. There was a strong acute phase response indicated by white blood cell (WBC) count (24,350/μl), C-reactive protein level (117 mg/l) and erythrocyte sedimentation rate (83 mm/h). Microcytic hypochromic anemia [red blood cells (RBCs) 3.88×10 6 /μl, hemoglobin (Hb) 8.2 mg/dl, hematocrit (Ht) 27.9%] was also noted. Chest X-ray showed a small infiltration in the left lower lung field, adjacent to the diaphragm. Abdominal computed tomography revealed an enlarged spleen with multiple cystic lesions, indicating intrasplenic abscesses (Fig. 1a). The patient's immunological parameters, including immunoglobulin levels, IgG subclass levels, lymphocyte subsets, proliferation to phytohemagglutinin, NK activity, and phagocytic and bactericidal activities of neutrophils, were normal. As the cystic lesions continued to enlarge, despite the intravenous administration of panipenem/betamipron and ampicillin, ultrasonography-guided puncture and aspiration were performed on the 10th hospital day. Three abscess lesions yielded a total of 20 ml of odorless yellowish-white pus (Fig. 1b). Cytological and histological examination of the aspirated material showed abscess and necrotic tissue without atypical cells. Neither bacteria nor fungus was identified by microbiological examination [smear, histology including Gram, periodic acid-Schiff (PAS), acid-fast and Warthin-Starry staining, and culture]. After the first aspiration, despite sequential and combined administration of antibiotics including meropenem, clindamycin, doxycycline, tobramycin, rifanpin, azithromycin and clarithromycin, small, low-density areas suppurated to form new abscesses one after another, necessitating a total of six sets (three-to-eight punctures per set) of aspiration (Fig. 1c).

Asymptomatic syphilitic massive necrosis of the spleen in late syphilis

“…Apart from tuberculosis, splenic abscess/ necrosis can be seen as a complication of endocarditis, in AIDS, typhoid fever, cat scratch disease, trauma of the spleen or induced by chemotherapy. [12][13][14] Due to the fact that the granulomatous massive necrosis of the spleen was investigated histopathologically, as well as that the heart valves were macroscopically normal in their appearance, no internal or external signs of trauma of the splenic region were found, and no medical data or autopsy findings of neoplasm were present, we conclude that syphilis was the causative agent of the necrosis of spleen.…”

Cat Scratch Disease – Heterogeneous in Clinical Presentation: Five Unusual Cases of an Infection Caused byBartonella henselae

“…The typical manifestation in 75 -90 % of cases is regional lymphadenitis following cutaneous inoculation. In 10 -25 % of the patients CSD presents with a variety of atypical clinical symptoms such as prolonged fever, abdominal pain, hepatosplenic lesions, visceral lymphadenopathy, or less commonly Raynaudlike syndrome, encephalitis, vertebral osteomyelitis, endocarditis, bacillary angiomatosis, encephalopathy, arthropathy or atypical pneumonia [5,6,10,12,13,15,18,21,26,28,29,31,34,36] . The recent development of new diagnostic tools such as PCR of tissue specimens [8,24,29] , reliable serology [16,29,33] and modern imaging techniques like MRI, CT and ultrasound [14,30] has facilitated the diagnosis of Bartonella henselae infection in atypical cases.…”