A 65-yr-old male patient was admitted to Chonnam National University Hospital because of fever and chills with drowsy mental status after hemodialysis. His symptoms and signs were acute onset. Fifteen years earlier, he was found to have diabetes and well controlled by insulin and oral hypoglycemics, and to have hypertension. Five years earlier, he had developed chronic renal failure due to diabetic complication. Three years earlier, he was operated native brachiocephalic arteriovenous fistula formation on his left arm and has been taken maintenance hemodialysis with 3 sessions in each week. Other past medical history including tuberculosis, hepatitis or abdominal surgery had not been known. He was non-smoker, and non-alcoholics. There was no history of trauma. His blood pressure was 130/80 mmHg and his body temperature was 38.1C on admission. On physical examination, there was diffuse tenderness on the abdomen, especially on the left hypochondrium. There was ecchymosis around the left brachiocephalic arteriovenous fistula area with tenderness and swelling. Auscultation of his chest revealed diastolic cardiac murmurs on apex.
On chest radiography and electrocardiogram, there was cardiomegaly. Biochemical analysis revealed that hemoglobin level was 8.2 g/dL, white blood cell count 11,500/microL, platelet count 84,000/microL, blood urea nitrogen level 25.0 mg/dL, and serum creatinine level 4.6 mg/dL, sodium 140 mEq/L, potassium 4.7 mEq/L, chloride 97 mEq/L, aspartate aminotransferase 28 IU/L, alkaline phosphatase 81 IU/L, serum albumin 3.4 g/dL, C-reactive protein 25.97 mg/dL, erythrocyte sedimentation rate 31 mm/hr, fibrinogen degradation product <5 microg/mL, D-dimer 0.4 mg/L (reference value 0-0.3), aPTT 37.3 sec, PT 13.1 sec/INR 1.08, and fibrinogen 716 mg/dL.
Abdominal sonography revealed two hypoechoic space occupying lesions and one cystic lesion in the spleen (Fig. 1). To differentiate splenic abscess or infarction, abdominal computed tomography (CT) was performed. Abdominal CT revealed multiple septated cystic lesions in the spleen, the largest 4.3 cm, and 2 cm low attenuated lesion in the left buttock area, compatible with multiple splenic abscesses and an abscess in the left buttock area (Fig. 2). We performed 2D-echocardiography, and found mobile hyperechoic mass on posterior mitral valve leflet tip with calcified valve. His brain CT was normal. We obtained blood samples at two different sites for bacteriologic culture and then started empirical antibiotics with ceftriaxone and aminoglycoside. He had continuous fever and left hypochondrial pain. Blood culture revealed methicillin sensitive Staphylococcus aureus (MSSA). We changed the antibiotics with cefazoline based on the drug sensitivity test. Inflammatory signs and hypoechoic lesions in the spleen did not respond to antibiotic therapy. On the 4th hospital day, emergency splenectomy was performed for the splenic abscess based on blood culture and abdominal CT. We aspirated blood from the evacuated spleen for bacteriologic culture and sent the evacuated spleen to pathologist for histologic diagnosis (Fig. 3). MSSA was cultured from the evacuated splenic blood, too. The pathologic findings showed splenic abscesses and infarction (Fig. 4). Antibiotic therapy was continued and he became afebrile. CBC findings and other chemical laboratory findings were returned to normal.