Splenic Abscess Fig. 2. The gross specimen shows splenomegaly. There was a cystic-like structure filled with pus (arrow) on the cross-sectional surface. scess are advances in imaging studies and an increased number of immunocompromised, trauma and cancer pa- tients.14,16 Splenic abscesses may often be misdiagnosed, because the signs and symptoms are nonspecific; neverthe- less, modern imaging has improved the process of their diag- nosis. The most common organisms in most reported series17 have been aerobic microbes, and particularly Streptococci and Escherichia coli. However, there are geographical vari- ations and population differences, as Llenas-Garcia, et al.18 reported a higher percentage of M. Tuberculosis in splenic absesses. A few cases with multiple splenic abscesses caused by Salmonella typhi have also been described in the litera- ture. Allal et al reported 400 patients with S. typhi and found splenic abscesses in 8 (2%) patients; of these only one had multiple splenic abscess.19 Torres, et al.20 reported 10 cases of typhoidal solitary splenic abscesses. Fever was the most common symptom seen in our series, followed by abdominal pain and chills. The triad of fever, left upper quadrant pain and a tender mass was suggested by Sarr and Zuidema21 However, we did not find that a ten- der mass was part of the common symptom triad. In this series, treatment was carried out by antibiotics alone, PCD or splenectomy. The mortality rate did not differ between the three groups, and it appeared that mortality was more related to the patient’s general underlying condition. All the mortality in this study was related to underlying solid tu- mors. The remaining patients recovered from their splenic abscess regardless of the treatment modality. Thus, based on these observations, the prognosis for these patients cannot be accurately predicted by the treatment methods. Twenty-two percent of our patients had PCD as a first line treatment. Percutaneous treatment of splenic abscess is an effective alternative to surgery; furthermore, it offers the the- oretical advantages of preserving immunologic function by avoiding splenectomy in young patients. The sucess rate of PCD for splenic abscess has been reported between 67% and 100%.13,22 The procedure is most likely to be successful when the abscess collection is unilocular and when its con- tent is liquefied enough to be drained.8 We prefer to proceed to PCD only when the above indication is met. In contrast with previous reports,4,13,14,18,23,24 we found that gram-negative K. pneumonia (22.2%) was one of the most frequently encountered microbacterial pathogens. A list of countries and their most common microbiological etiolo- gies are presented in Table 3. Primary splenic abscess due to K. pneumonia has rarely been reported. In the present study, we found that coexisting liver abscesses were found in 16.7% of patients. K. pneumonia accounted for 100% of the coexisting liver abscesses. We believe that the higher per- centage of K. pneumonia in our study is most likely due to a sequela of metastatic infection from the liver to the spleen, or a coinfection of both. Three out of four patients had a single abscess pocket. The remaining one patient had huge single abscess with multiple satellite abscess pockets. We prelimi- narily suggest that K. pneumonia may be related to creating a large single abscess rather than developing multiple splenic abscesses. These results indicate the significance of the role of gram negative bacterial infection in splenic abscesses. There is no gold standard treatment for splenic abscess. Traditional treatment includes appropriate antimicrobial ther- apy with or without splenectomy.15 There are a number of studies in favor of spleen preservation and management us- ing PCD.8,13 Percutaneous aspiration or drainage may be used as a bridge to surgery, allowing nonoperative healing for splenic abscess patients who are at risk for surgery, and helps avoid the risk of a fulminant and potentially life-threatening infection. The success rate for PCD in our series was 50%. In conclusion, the best therapeutic approach for splenic abscess is still a matter of debate. We agree with the tradi- tional treatment of antibiotics with or without splenectomy. However, based on our experience and the current litera- ture, percutaneous aspiration of splenic abscess can be used as a bridge to surgery for those patients who are critically ill or who have several comorbidities. Early diagnosis of splenic abscess requires a high degree of suspicion. Most of our pa- tients presented with unexplained fever, abdominal pain and radiologic evidence of pathology in the left chest or ab- domen, and these signs and symptoms should lead to suspi- cion of splenic abscess. Abdominal CT and ultrasonography Yonsei Med J http://www.eymj.org Volume 52 Number 2 March 2011 291