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Despite the involvement of six specialties, the cause of an apparent splenic abscess eluded diagnosis until death.
A man of 68 reported anorexia, nocturnal sweats and left upper quadrant pain. On examination he was cachectic, with a mass in the left hypochondrium and signs of a left pleural effusion. There was no peripheral lymphadenopathy. Haemoglobin was 8.1 g/dL with a normocytic, normochromic picture. The white cell count was within normal limits and a blood film was unremarkable. C-reactive protein, urea and electrolytes and liver function tests were all normal. Blood and urine cultures yielded no growth. CT revealed a lesion in the spleen 22 cm in maximum diameter and consistent with a fluid collection (Figure 1). A large left-sided pleural effusion was also noted, without evidence of mediastinal or abdominal lymphadenopathy. Malignant disease was suspected but pleural fluid repeatedly showed only chronic inflammatory cells. Upper gastrointestinal endoscopy, bone marrow biopsy, and plasma and urine electrophoresis were likewise negative.
The patient, initially admitted under the care of the gastroenterology team, was then discussed at a surgical–medical multidisciplinary meeting with a view to splenectomy, both for diagnostic and therapeutic purposes. On revisiting the history it was then brought up that there had been a suggestion of a blow to the patient's left upper quadrant after he had fallen heavily onto the handles of his wheelbarrow some months before the start of his symptoms. The consensus was that the lesion in the spleen might be an aseptic collection, perhaps a liquefied haematoma. There was a general reluctance to proceed directly to splenectomy in view of the patient's frailty, and percutaneous drainage was mooted. This was done under CT guidance and a pigtail drain was inserted. Fluid with the appearance of frank pus was drained but no organisms were seen on microscopy and cultures were negative. The drain was left in situ for three weeks and continued to yield small quantities but the patient did not improve. Repeated examinations of fluid samples were unrewarding. On further CT the collection had increased in size and density and a lesion was seen at the apex of the right lung. Abdominal lymphadenopathy was not evident. In an effort to obtain a tissue diagnosis, the lung lesion was approached via flexible bronchoscopy but biopsy proved impossible and washings were negative for malignant cells. Thoracoscopy and biopsy were proposed but the patient died as he was being transferred to a cardiothoracic unit. At necropsy he was found to have a diffuse B-cell lymphoma involving the spleen, stomach, lower lobe of the left lung and apex of the right lung.
Non-Hodgkin lymphoma can show itself anywhere in the body but we have found only one previous report of it mimicking a splenic abscess.1,2 Although our initial clinical diagnosis of haematological malignancy ultimately proved correct, it was impossible to confirm during life. The story of possible splenic trauma, raising an alternative diagnosis of splenic haematoma and collection, turned out to be irrelevant. Splenic abscesses are uncommon and tend to occur in the immunocompromised.3 On drainage they usually yield frank pus, and this is what we appeared to obtain; in retrospect this must have been necrotic tumour material.