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Year : 2011  |  Volume : 54  |  Issue : 3  |  Page : 638-639
Actinomycotic splenic abscess: A rare case report

Department of Pathology, Indira Gandhi Medical College and Research Institute, Pondicherry, India

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Date of Web Publication20-Sep-2011

How to cite this article:
Sinhasan SP. Actinomycotic splenic abscess: A rare case report. Indian J Pathol Microbiol 2011;54:638-9

How to cite this URL:
Sinhasan SP. Actinomycotic splenic abscess: A rare case report. Indian J Pathol Microbiol [serial online] 2011 [cited 2021 Jan 24];54:638-9. Available from: https://www.ijpmonline.org/text.asp?2011/54/3/638/85127

Splenic abscess is a rare clinical entity with a reported frequency of 0.05-0.7%. About 600 cases have been described so far in the international literature. [1] It is a potentially serious surgical problem with associated high mortality when not treated. Splenic abscess due to actinomyces is very rare. [2] Although the portal of entry of abdominal actinomycosis is thought to be via the gastrointestinal tract, how it reaches the spleen is open to speculation. Primary splenic actinomycosis without other organ involvement is extremely rare entity and we report one such case.

A 52-year-old lady presented to with continuous dull aching upper abdominal pain of few weeks duration. She was screened for hepatitis, typhoid, tuberculosis, atypical pneumonia and human immunodeficiency virus. All proved to be negative. Multiple blood and stool cultures grew no pathogens. An abdominal ultrasound revealed splenic abscess of 2 cm diameter. She underwent percutaneous drainage of the same. The abscess culture yielded no organisms. She was quite asymptomatic for a period of 3 months, after which she again developed dull aching abdominal pain, on and off fever. The severity of pain got worsened gradually and she was admitted again. Repeat abdominal ultrasound revealed mild splenomegaly and multiple splenic abscesses largest measuring 3.2 cm diameter. Splenectomy was done under general anesthesia.

Spleen was moderately enlarged and external surface showed multiple grey-white elevated nodules. Cut section of spleen showed multiple grey-white nodular areas with yellow colored purulent material (sulfur granule) oozing out [Figure 1].
Figure 1: Gross specimen: Spleen showing multiple yellowish purulent areas containing sulfur granules with areas of dense fi brosis

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Multiple sections from spleen revealed classical actinomycotic colonies consisting of centrally situated radiating structures with peripherally situated eosinophilic material-hyaline club (Splendore-Hoeppli material), surrounded by rim of exudate containing dense mixed inflammatory cell infiltrate with granulomatous response [Figure 2]. The classic "sunray appearance" of the slender, filamentous bacteria was evident in gram-stained sections [Figure 3]. There was dense fibrosis in white pulp with foreign body giant cell reaction and an occasional Gamna Gandy bodies. The Gomori's methenamine silver (GMS) stain confirmed actinomycotic colonies [Figure 4]. Postoperatively, her condition continued to improve and was discharged one week later on oral antibiotics.
Figure 2: Histopathology: Actinomycotic colonies consisting of centrally situated radiating structures with peripheral eosinophilic material and dense inflammation (H and E, ×40)

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Figure 3: Gram positive actinomycotic colony. Note Sunray appearance (Gram stain, ×400)

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Figure 4: Silver stain positive actinomycotic colonies (GMS, ×200)

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The splenic abscess remains a substantial diagnostic challenge as clinical presentation is variable and may mimic other chronic diseases such as chronic granulomatous infections, malignant lesions and inflammatory bowel diseases. The classical triad of fever, left upper quadrant pain, and splenomegaly is seen in only about one-third of patients. Human actinomycosis is most commonly caused by Actinomyces israelii, gram-positive, anaerobic filamentous bacteria. [1] In vivo growth of actinomycetes usually results in the formation of characteristic clumps called grains or sulfur granules. [2] There are three major clinical presentations: cervicofacial, abdominal and thoracic. The splenic actinomycosis is extremely rare, especially as a single organ involvement. [3] Frequently, definitive diagnosis is only made after surgery and is based on culture of the organisms, the presence of 'sulfur granules' in the specimen and detailed histopathological examination. Culture yields are low, less than 60% in one report. [4] Prior administration of broad-spectrum antibiotics, failure to use correct culture medium and the slow growth rate of the organisms, all contribute to the negative culture yields. [4]

Percutaneous drainage of splenic abscess has gained acceptance as an effective and less invasive treatment method than surgical intervention in selected patients. [5] The reported success rate of percutaneous drainage is 67-100%. Such drainage preserves the spleen and avoids the risk of overwhelming postsplenectomy infections. However the presence of multilocular abscesses, ill-defined cavities, septations, and necrotic debris typically do not respond to percutaneous drainage. Multilocular abscesses, fungal abscesses, infected hematomas, abscesses with thick contents, and abscesses unresponsive to percutaneous drainage, however, should be subjected to splenectomy. Untreated, a splenic abscess may rupture into the peritoneal or pleural cavity or bowel, and the prognosis in these patients is bleak. [5]

In conclusion, splenic actinomycosis is an uncommon infectious disease that must be suspected in patient diagnosed as multilocular splenic abscess, poorly responding to antibiotic coverage or presenting with a recurrence. Accurate diagnosis is largely made with an examination of the specimen removed during surgery and demonstrating the presence of sulfur granules. Prognosis is excellent with correct antibiotic treatment but recurrence occurs if the duration of antibiotic cover is inadequate.

   Acknowledgments Top

I thank Dr. Nagesha K.R., Associate Professor of Pathology, HIMS, Hassan, for providing case details and Dr. Sharanabasav. M. Chowkimath, Assistant Professor of Pathology, KIMS, Hubli, for his support.

   References Top

1.Fotiadis C, Lavranos G, Patapis P, Karatzas G. Abscesses of the spleen: Report of three cases. World J Gastroenterol 2008;14:3088-91.  Back to cited text no. 1
2.Azarpira N, Ghasemzadeh B. Splenic actinomycosis: Unusual presentation. Iranian J Med Sci 2005;30:141-3.  Back to cited text no. 2
3.Chan PM, Chong SM, Ng BK, Chan ST. Splenic actinomycosis. J R Coll Surg Edinb 1999;44:344-5.  Back to cited text no. 3
4.Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36-year period. Arch Intern Med 1975;135:1562-8.  Back to cited text no. 4
5.Murray AW, Macgregor AB. A case of multiple splenic abscesses managed non-operatively. J R Coll Surg Edinb 2000;45:189-91.  Back to cited text no. 5

Correspondence Address:
Sankappa P Sinhasan
Department of Pathology, Indira Gandhi Medical College and Research Institute, Pondicherry - 605 009
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.85127

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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