Surgical infective endocarditis and concurrent splenic abscess requiring splenectomy: a case series and review of the literature

Management of embolic splenic abscess secondary to aortic valve endocarditis - case report and review of literature

BACKGROUND

Splenic abscess is a serious complication associated with infective endocarditis. There is still contradicting evidence regarding the optimal treatment pathway including timing of valve intervention and the approach for managing splenic foci.

CASE PRESENTATION

We present a case of a hybrid staged approach in which we successfully performed a laparoscopic splenectomy following percutaneous abscess drainage and a delayed aortic valve replacement.

CONCLUSIONS

A multidisciplinary teamwork is fundamental in providing optimal care for patients with distant complications associated with infective endocarditis. Our hybrid approach seems safe and feasible.

Splenic Embolism in Infective Endocarditis: A Systematic Review of the Literature with an Emphasis on Radiological and Histopathological Diagnoses

Infective endocarditis (IE) is characterised by fever, heart murmurs, and emboli. Splenic emboli are frequent in left-sided IE. A systematic review of the literature published on splenic embolism (SE) between 2000 and 2023 was conducted. Search strategies in electronic databases identified 2751 studies published between 1 January 2000 and 4 October 2023, of which 29 were finally included. The results showed that the imaging tests predominantly used to detect embolisms were computed tomography (CT), magnetic resonance imaging, positron emission tomography (PET)/CT, single-photon emission computed tomography/CT, ultrasound, and contrast-enhanced ultrasound. More recent studies typically used 18F-FDG PET-CT. The proportion of SE ranged from 1.4% to 71.7%. Only seven studies performed systematic conventional CT screening for intra-abdominal emboli, and the weighted mean frequency of SE was 22% (range: 8-34.8%). 18F-FDG PET-CT was performed systematically in seven studies, and splenic uptake was found in a weighted mean of 4.5%. There was a lack of uniformity in the published literature regarding the frequency and management of splenic embolisation. CT scans were the most frequently used method, until recently, when 18F-FDG PET-CT scans began to predominate. More data are necessary regarding the frequency of SE, especially focusing on their impact on IE management and prognosis.

Splenic abscess due to non-operative management of splenic injury: a case report

BACKGROUND

Splenic abscess is a rare disease, with incidence of 0.2-0.7% in previous studies. It often appears with left upper quadrant abdominal pain, fever, chills. Splenic abscess often happens because of hematogenous spreading of infections, endocarditis, angioembolization and some other rare reasons. Treatment relies on one of these two methods: percutaneous drainage or surgery.

CASE PRESENTATION

A 68-year-old diabetic Asian female (Asian woman) presented with generalized abdominal pain, low blood pressure, tachycardia, fever, lethargy and elevated level of blood sugar. She had history of conservative therapy in intensive care unit due to blunt abdominal trauma and splenic injury. She had a huge splenic abscess in ultrasonography and computed tomography scan so she went under splenectomy. Our patient had a splenic abscess without performing any intervention like angioembolization.

CONCLUSION

Immune compromised patients who are selected for nonoperative management after splenic injury need close follow up and evaluating about abscess formation for at least 2 weeks. Early diagnosis and treatment with two methods including percutaneous drainage or splenectomy should be considered and it depends on patient's risk factors, vital signs, general conditions and presence or absence of sepsis.

Splenic Abscesses in Endocarditis: A Rare Disease with High Mortality. The Experience of a Heart Institute in Brazil

INTRODUCTION

Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition.

METHODS

Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed.

RESULTS

Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%.

CONCLUSION

Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.

Splenic Abscess in the New Millennium: A Descriptive, Retrospective Case Series

Background

Splenic abscess is a rare infection often resulting from hematogenous spread. Immunocompromised states are commonly comorbid, and the microbiology is heterogeneous.

Methods

We conducted a retrospective review of 33 cases identified by convenience sampling. Cases were treated in our institution’s hospital system between May 2012 and February 2021 and classified as proven or probable based on predetermined criteria.

Results

The median age was 57 years, and 58% were men. Common underlying diseases included diabetes mellitus (30%), pancreatic disease (30%), and hematological malignancy (15%). The most common mechanism of pathogenesis was hematogenous spread (n = 13). Escherichia coli, enterococcal spp., and anaerobes were frequently implicated. One case was discovered at autopsy and excluded from subsequent analyses. The median duration of antimicrobial therapy (range) was 45 (5–525) days, and the median length of index hospitalization was 20 days. Percutaneous drainage by interventional radiology was common (17 of 32; 53%), and 6 patients underwent splenectomy. Treatment success was achieved in 14 of 32 cases (44%), with clinical stability in 3 of 32 cases (9%). Failures occurred in 13 of 32 (41%) cases, 2 of whom died from splenic abscesses. Two patients (2 of 32) were lost to follow-up.

Conclusions

To our knowledge, this is the largest North American series since the turn of the century and the first to distinguish between proven and probable cases. As reflected in our series, patients with splenic abscess may require prolonged hospitalizations and courses of antimicrobial therapy. Improvements in management are needed.

Percutaneous drainage and staged valve replacement followed by laparoscopic splenectomy in infective endocarditis with splenic abscess

Splenic abscess is a severe complication of infective endocarditis. The need for splenectomy to control prosthetic valve infection remains controversial. Here, we present the case of a 49-year-old man who complained of fever and general fatigue. Blood cultures grew Group G Streptococcus, and intravenous antibiotics were started. Abdominal computed tomography showed splenic abscess; thus, percutaneous drainage was performed. Two-dimensional transthoracic echocardiogram revealed a mobile vegetation on the right coronary cusp of the aortic valve with mild aortic regurgitation. The patient underwent aortic valve replacement using a 23-mm SJM Regent mechanic valve, followed by laparoscopic splenectomy 3 days later. The patient was asymptomatic without recurrence of infection 13 months postoperatively. Current guidelines recommend that splenectomy should be performed first, followed by valve replacement. However, we performed valve surgery first because of the risk of embolism. Depending on the patient's condition, performing splenic drainage and valve replacement first may be considered.

Native Aortic Valve Endocarditis Complicated by Splenic Infarction and Giant Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm-A Case Report and Brief Review of the Literature

Background: Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is an unusual complication related to various injuries or conditions which involve the mitro-aortic region; it communicates with the left ventricular outflow tract and is associated with a high-risk of redoubtable complications or sudden death. The cerebral and splenic localizations are frequently seen as manifestations of systemic embolism in infective endocarditis. Currently, there are no specific recommendations related to the diagnosis, management, treatment, or further evolution of patients with P-MAIVF and concomitant splenic infarction. This paper presents the case of a 43-year-old Caucasian woman with a late diagnosis of mixed bicuspid aortic valve disease, affected by an under-detected and undertreated episode of infective endocarditis leading to asymptomatic P-MAIVF. Prime clinical and imagistic diagnosis of splenic infarction indicated further extended investigations were required to clarify the source of embolism. Methods: Integrated multimodality imaging techniques confirmed the unexpected diagnosis of P-MAIVF. Results: The case had a fatal outcome following an uncomplicated yet laborious cardiac surgery. Patient death was attributed to a malignant ventricular arrhythmia. Conclusion: The present case raises awareness by highlighting an unexplained and unexpected splenic infarction association with P-MAIVF as a result of infective endocarditis related to mixed bicuspid aortic valve disease.